PAUL  B.  HOEBER 

Medical  Books 
230  E.  50th  St.,  N.Y. 


BRj^ 


5c</^ 


Columbia  (Hnitiersittj) 

tntl)e€itpoflmgork 

College  of  ^Ij^jSicianfl!  anb  ^urgeonjf 
Hitirarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatmentoffract1903scud 


THE  TREATMENT 


OF 


FRACTURES 


WITH  NOTES  UPON  A  FEW 
COMMON    DISLOCATIONS 


BY 

CHARLES    LOCKE    SCUDDER,    M.D. 

SURGEON    TO    THE    MASSACHUSETTS    GENERAL   HOSPITAL 


ffourtb  leMtton,  ITbotouGbl^  1Revtse^ 


mitb  essmiustrations 


PHILADELPHIA,  NEW  YORK,  LONDON 

W.    B.   SAUNDERS   &   COMPANY 
1903. 


CEtjiJLfJLy 


Set  ui>,  jiiintcil,   and    cupyriglited    April,   ]90(l.     Revised,  reset,  reprinted,  jind  recopy- 
'    righted  January,  1901.     Revised,  reset,  reprinted,  recopyrighted  August,  1902. 
Revised,  reset,  electrotyped,  j)rinted,  and  recopyrighted  November,  1903. 


Copyright,  1903,  by  W.  B.  Saunders  &  Coiii]>any, 


Registered  at  Stationers'  Hall,  Lniidon,  England. 


PRESS    OF 
V/      B.    SAUNDERS    &    COMPANY. 


TO 
ARTHUR  TRACY  CABOT,  A.M.,  M  D. 


PREFACE  TO  THE  FOURTH  EDITION 


In  this  edition  many  half-tones  are  introduced,  increasing  the 
accuracy  of  illustration.  Additions  are  made  to  the  text  at 
various  points.  A'-ray  plates  of  the  epiphyses  at  different  ages 
have  been  arranged.  These  will  be  found  of  value  not  only  as 
an  anatomical  study  but  in  the  appreciation  of  epiphyseal  lesions. 

I  wish  to  thank  Dr.  Thomas  Dwight,  of  the  Harvard  Medical 
School,  for  the  use  of  his  most  valuable  preparations  of  the  epiph- 
yses; also  Mr.  Walter  Dodd,  of  the  Massachusetts  General  Hos- 
pital, for  his  care  and  interest  in  the  securing  of  the  x-rays.  Mr. 
Green,  of  the  Medical  School,  made  the  photographs  of  patho- 
logical specimens. 

The  publishers  suggested  the  introduction  of  the  subject  of 
dislocations  and  at  their  solicitation  I  have  added  a  chapter  upon 
this  subject.  In  this  brief  chapter  I  have  stated  the  generallv 
accepted  methods  of  treating  a  few  of  the  ordinary  dislocations. 

I  am  replacing  the  tracings  of  x-rays  of  types  of  fracture  by 
half-tones  of  the  x-ray  plates  themselves. 

The  kindness  and  liberality  of  the  publishers  have  again  enabled 
me  to  enhance  the  value  of  the  book  through  freedom  of  illustra- 
tion. 

Charles  T.  Scudder 
189  Beacon  Street,  Boston, 
November,  1903 


PREFACE  TO  THE  FIRST  EDITION 


The;  general  employment  of  anesthesia  in  the  examination 
and  the  initial  treatment  of  fractures,  especially  of  those  near 
or  involving  joints,  has  made  diagnosis  more  accurate  and  treat- 
ment more  intelligent.  The  application  of  the  Rcntgen  ray  to 
the  diagnosis  of  fracture  of  bone  has  already  contributed  much 
toward  an  accurate  interpretation  of  the  physical  signs  of  frac- 
ture. This  greater  certainty  in  diagnosis  has  suggested  more 
direct  and  simpler  methods  of  treatment.  Antisepsis  has  opened 
to  operative  surgery  a  very  profitable  field  in  the  treatment  of 
fractures.  The  final  results  after  the  open  incision  of  closed 
fractures  emphasize  the  fact  that  anesthesia,  antisepsis,  and  the 
Rontgen  ray  are  making  the  knowledge  of  fractures  more  exact, 
and  their  treatment  less  complicated.  The  attention  of  the  stu- 
dent is  diverted  from  theories  and  apparatus  to  the  actual  con- 
ditions that  exist  in  the  fractured  bone,  and  he  is  encouraged  to 
determine  for  himself  how  to  meet  the  conditions  found  in  each 
individual  case  of  fracture. 

This  book  is  intended  to  serve  as  a  guide  to  the  practitioner 
and  student  in  the  treatment  of  fractures  of  bone.  In  the  follow- 
ing pages  many  of  the  details  in  the  treatment  of  fractures  are 
described.  So  far  as  possible  these  details  are  illustrated.  A 
few  very  unusual  fractures  are  omitted.  Mechanical  simplicitv 
is  advocated.  An  exact  knowledge  of  anatomy  combined  with 
accurate  observation  is  recognized  as  the  proper  basis  for  the 
diagnosis  and  treatment  of  fractures.  The  expressions  "closed" 
and  "open"  fracture  are  used  in  place  of  "simple"  and  "com- 
pound" fracture.  "Closed"  and  "open"  express  definite  condi- 
tions, referring  to  the  freedom  from,  or  liability  to.  bacterial  infec- 
tion. The  old  expressions  are  misleading  despite  their  long 
usage.     Theories    of    treatment    are    not    discussed.     Tvpes    of 


12  PREFACE 

dressings  for  special  fractures  are  described.  Many  illustrative 
clinical  cases  are  omitted  i)uri)osely. 

The  tracings  of  the  Rontgen  rays,  which  have  been  very  gen- 
erallv  used  to  illustrate  the  sites  and  the  displacements  of  frac- 
tures, have  been  the  subject  of  careful  study.  Each  tracing 
represents  the  combined  interpretation  of  the  plate  made  by 
skilled  observers  who  were  in  every  instance  familiar  with  the 
clinical  aspects  of  the  case.  The  writings  of  many  who  have 
ct)ntributed  their  experience  to  the  literature  of  fractures  have 
been  consulted.  Those  to  whom  I  feel  indebted  for  suggestions 
are  mentioned  in  the  section  on  Bibliography.  References  to 
literature  are  not  made  in  the  text. 

I  take  this  opportunitv  to  extend  my  thanks  to  the  members 
of  the  Surgical  Staff  of  the  JNIassachusetts  General  Hospital  for 
their  courtesv  in  permitting  me  to  study  cases  of  fracture  of  the 
lower  extremitv  in  the  wards  of  the  hospital,  and  to  Professor 
Thomas  Dwight  for  the  use  of  valuable  anatomical  material.  I 
also  thank  Dr.  F.  J.  Cotton  for  an  untiring  interest  in  the  pro- 
duction of  most  of  the  drawings,  and  in  the  search  for  fracture 
literature.  The  half-tones  are  made  from  photographs  taken 
under  the  direct  superintendence  of  the  author.  Due  credit  for 
illustrations  not  original  is  given  next  the  legend. 

I  wish  to  thank  Mr.  Walter  Dodd  for  his  courtesy  and  interest 
connected  with  the  production  of  the  Rontgen-ray  plates,  and 
Dr.  H.  P.  Mosher  for  kind  assistance. 

The  chapter  on  the  Rontgen  ray  is  written  by  Dr.  E.  A.  Codman. 

Charles  L.  Scudder 


TABLE  OF  CONTENTS 


CHAPTER  I  PAGE 

Fractures  of  the  Skull 17 

Fractures  of  the  Vault 26 

Fractures  of  the  Base 26 

Treatment : 35 

Later  Results  of  Fracture  of  the  Skull 39 

CHAPTER  II 

Fractures  of  the  Nasal  Bones 45 

The  Nasal  Septum 48 

Treatment 50 

Fractures  of  the  Malar  Bone 53 

Treatment 56 

Fracture  of  the  Superior  Maxilla 57 

Treatment 58 

Fractures  of  thr  Inferior  Maxilla 60 

Treatment 63 

CHAPTER  III 

Fractures  of  the  Vertbbr.^ 73 

Treatment 81 

Gunshot  Fractures  of  the  Vertebrse 93 

CHAPTER  IV 
Fractures  of  the  Ribs 95 

CHAPTER  V 
Fractures  of  the  Sternum 101 

CHAPTER  VI 

Fractures  of  the  Pelvis 104 

Treatment 106 

Rupture  of  the  Urethra 109 

Rupture  of  the  Urinary  Bladder   110 

CHAPTER  VII 

Fractures  of  the  Clavicle 112 

Treatment  in  Adults 115 

Treatment  in  Children 121 

Operative  Treatment 123 

13 


14  TABLE    OF    COXTHNTS 

CHAPTER   \III  PAGE 

Fractures  of  the  Scapula 125 

Treatment 128 

CHAPTER  IX 
Fractures  of  the   Humerus . 130 

Fractures  of  the  Upper  End  of  the  Humerus 130 

Diagnosis 134 

Treatment 146 

Fracture  of  the  Upper  End  of  the  Humerus  with  a  Dislocation  of  the 

i ' ppcr  Fragment 151 

Fractures  of  the  Shaft  of  the  Humerus 153 

Fractures  of  the  Sliaft  with  Little  Displacement 157 

Fractures  of  the  Shaft  with  Considerable  Displacement  -  _.  . 162 

Fractures  of  the  vShaft  in  the  New-born 164 

The  Musculospiral  Nerve  in  Fracture  of  the  Humerus 164 

Malignant  Disease  Associated  with  Fracture  of  Bone 167 

Fractures  of  the  Elbow 167 

Diagnosi  s . 174 

Treatment 182 

CHAPTER  X 

Fractures  ok  the  Bones  of  the  Forearm 199 

Fractures  of  Both  Radius  and  Ulna 199 

Treatment 210 

Nonunion  of  Fractures 220 

Fractures  of  the  Olecranon 222 

Treatment 226 

Tetanus 231 

Colles'  Fracture 232 

Diagnosis 240 

Treatment 246 

CHAPTER  XI 

Fractures  of  the  Carpus,  Metacarpus,  and  Phalanges 256 

Fractures  of  the  Carpus 256 

Fractures  of  the  Metacarpus 259 

Fractures  of  the  Phalanges    265 

Open  Fractures  of  the  Phalanges 268 

CHAPTER  XIT 

Fractures  of  the  Femur 270 

Fracture  of  the  Hip  or  Neck  of  the  Femur 270 

Treatment 280 

Operative  Treatment -  291 

Fracture  of  the  Neck  of  the  Fennir  in  Childhood 291 


TABIvE   OF   CONTENTS  1 5 

PAGE 

Fracture  of  the  Shaft  of  the  Femur 293 

Treatment 296 

Subtrochanteric  Fracture  of  the  Femur .309 

Supracondyloid  Fracture  of  the  Femur 311 

Ambulatory  Treatment  of  Fracture  of  the  Thigh 314 

Fracture  of  the  Thigh  in  Childhood 319 

Separation  of  the  Lower  Epiphysis  of  the  Femur 324 

Treatment 329 

Traumatic  Gangrene . 332 

Septicemia 332 

Malignant  Edema 332 

Fat   Embolism 333 

CHAPTER  XIII 

Fractures  of  the  Patella 335 

Treatmerit 340 

Open  Fracture  of  the  Patella 349 

Operation  in  Recent  Closed  Fractures  of  the  Patella 354 

CHAPTER  XIV 

Fractures  of  the  Leg 357 

Treatment 368 

Fractures  with  Little  or  No  Displacement 368 

Fractures  with  Considerable  Immediate  Swelling 370 

Fractures  Difficult  to  Hold  Reduced 383 

Treatment  of  Open  Fractures  of  the  Leg 386 

Thrombosis  and  Embolism 394 

Pott's  Fracture 394 

Treatment . 397 

Open   Pott's   Fracture 408 

CHAPTER  XV 
Fractures  of  the  Bones  of  the  Foot 409 

Fracture  of  the  Astramlus 409 

Fracture  of  the  Os   Calcis 411 

Open  Fracture  of  the  Astragalus  and  Os  Calcis 415 

Fracture  of  the  Metatarsal  Bones 415 

Fracture  of  the  Phalanges 417 

CHAPTER  XVI 
Anatomical  Facts  Regarding  the  Epiphyses 418 

CHAPTER  XVII 

Gunshot  Fractures  of  Bone 431 

Treatment 438 


l6  TABLE    OF    CONTENTS 

CHAPTER   X\III  PAGE 

The  Rontgen  Rav  axu  Its  Relation  to  Kkactukes 444 

Bv  E.  A.  CouMAN,  M.D. 

CHAPTER  XIX 

The  Emplovmext  ok  Plaster-of-Paris 460 

CHAPTER   XX 

The  Ambl-latory  Treat.%jext  of  Eractikes 481 

CHAPTER  XXI 

Notes  upon  a  Few  Common  Dislocations 489 

Dislocation  of  the  Cervical    \'ertebrse 489 

Dislocation  of  tlie  Jaw   496 

Dislocation  of  the  Clavicle 500 

Dislocation  of  the  Shoulder 501 

Recurrent   Dislocations  of  the  Shoulder : 507 

Old  Unreduced  Dislocations 507 

Dislocation  of  tlie   EHiovv 509 

Dislocation  of  the  Thumb 512 

Dislocation  of  the   Hip 515 

Dislocation  of  the  Patella    518 


BIBLIOGRAPHY 519 

INDEX 523 


THE 

Treatment  of  Fractures 


CHAPTER  I 
FRACTURES  OF  THE  SKULL 

It  is  unwise  to  consider  the  treatment  of  fracture  of  the  skull 
apart  from  a  more  or  less  systematic  review  of  traumatic  lesion 
of  the  brain. 

The  skull  is  the  brain's  protection.  In  cases  of  fracture  of 
the  skull  the  injury  to  the  brain  is  of  paramount  importance. 
The  immediate  damage  to  the  brain  may  be  caused  by  direct 
pressure  of  bony  fragments,  by  pressure  due  to  hemorrhage 
from  torn  vessels  within  the  skull,  by  bruising  of  the  brain 
itself,  or  by  cerebral  edema.  Great  interest  attaches  to  serious 
head-injuries,  not  only  because  the  brain  may  be  damaged, 
but  more  especially  because  the  lesions  are  often  obscured  by 
an  intact  scalp.  A  proper  determination  of  the  conditions 
existing  after  a  given  head-accident  necessitates  careful  obser- 
vation of  symptoms,  combined  with  good  judgment  in  inter- 
preting the   signs  present. 

Concussion  and  Contusion  of  the  Brain. — A  concussion 
and  a  contusion  of  the  brain  associated  with  minute  bruising 
of  brain-tissue  will  exist  after  all  serious  injuries  to  the  skull. 

The  symptoms  of  concussion  are  varied  according  to  the 
severity  of  the  injury.  Following  slight  concussion,  the  in- 
dividual is  stunned  by  the  accident;  there  is  simple  vertigo, 
possibly  mental  confusion  lasting  but  a  short  time.  After  severe 
concussion  there  will  follow  a  momentarv  loss  of  consciousness, 

2  17 


1 8  FRACTURES    OF    THE    SKULL 

or  there  mav  be  unconsciousness  of  longer  duration.  Vomiting 
mav  occur.  Headache  will  probably  be  present.  Following 
a  still  more  severe  concussion,  the  patient  will  be  profoundly 
unconscious  for  a  long  period.  The  sphincters  may  be  relaxed  j 
hence  involunlarv  micturition  and  defecation  will  occur  when 
the  bladder  and  rectum  become  overdistended.  Retention  of 
urine  and  feces  is  the  sign  immediately  after  the  injury.  In- 
continence is  the  evidence  of  overdistention  of  the  viscus  in 
these  cases.  The  pulse  will  become  feeble  and  slow  along  with 
the  general  systemic  depression.  The  pupils  still  react  to 
light.     The    temperature   will   be    subnormal.     It   is   impossible 


Fig.    I. — Fracture   of   skull,  middle   meningeal   hemorrhage.      Plxlradural  blood-clot    (after 

Helferich). 

clinically  to  distinguish  between  concussion  and  contusion  of 
the  brain.  The  pathological  differences  are  more  or  less 
artificial. 

Laceration  of  the  Brain. — If  there  is  serious  laceration  of  the 
brain,  the  symptoms  of  concussion  may  be  present  to  a  marked 
degree,  and  will  be  characterized  by  immediate,  pronounced,  and 
long-continued  unconsciousness.  After  recovery  from  the  initial 
shock  of  the  accident  fever  will  be  present,  which  may  rise  to 
103°  or  104°  F.  Concussion  alone  is  never  associated  with 
feverishness.  Early  fever  is  a  sign  of  laceration.  Mental  irri- 
tability and  restlessness  will  mark  returning  consciousness.  If 
the  motor  areas  of   the  brain    are    involved,  signs    of    irritation 


EXTRADURAIv    HEMORRHAGE  19 

will  appear — namely,   muscular  twitchings  and   spasms  accord- 
ing to  the  motor  centers  implicated. 

Compression  of  the  Brain. — vSlight  hemorrhages  do  not 
cause  symptoms  of  compression ;  neither  do  slight  depressions 
of  the  cranial  bones.  Before  symptoms  of  compression  appear, 
the  cranial  contents  must  be  impinged  upon  to  a  very  consider- 
able extent.  If  the  compression  is  sudden  and  limited,  there 
is  an  irritation  of  the  parts  involved,  which  is  manifested  by 
restlessness  and  delirium  and  by  twitching  of  certain  groups 
of  muscles;  the  pulse  is  hard  and  slow.  If  the  compression  is 
gradual,  whether  it  be  localized  or  dilTused,  the  brain  accommo- 
dates itself  for  some  time  to  the  new  conditions;  the  appear- 
ance of  the  symptoms  of  local  pressure  is  delayed,  although 
they  may  be  relatively  sudden  in  their  onset.  Following  the 
muscular  spasms  and  twitchings  due  to  the  sudden  onset  of 
pressure  there  may  appear  symptoms  of  paresis  and  paralysis. 
Loss  of  power  in  the  face  or  arm  or  leg  indicates  a  lesion  about 
the  fissure  of  Rolando,  upon  the  opposite  side.  Loss  of  power, 
for  example,  in  the  right  arm  and  right  leg  indicates  that  the 
brain  lesion  is  about  the  fissure  of  Rolando  upon  the  left  side 
of  the  brain.  If  there  is  pressure  upon  the  third  nerve  at  the 
base  of  the  skull,  dilatation  of  the  pupil  upon  the  side  opposite 
to  the  pressure  will  be  noticed.  This  pupil  will  not  react  to 
light.  As  the  pressure  of  the  hemorrhage  increases,  the  symp- 
toms will  again  become  more  general;  convulsive  movements 
of  the  limbs  and  body  appear,  and  the  drowsiness  or  stupor 
increases  to  profound  unconsciousness;  the  pulse  becomes  rapid 
and  small;  and  the  respiration  frequent,  shallow,  and  sighing, 
or  it  passes  into  stertor  and  Cheyne-Stokes'  breathing  as  the 
condition  becomes  immediately  grave;  the  temperature  rises 
high.  Focal  symptoms  may  exist  from  pressure  by  bone  or 
blood-clot,  apart  from  loss  of  consciousness. 

Extradural  Hemorrhage  (see  Figs,  i,  2,  3). — A  most  important 
symptom  of  traumatic  intracranial  hemorrhage  is  the  interv'al  of 
consciousness  that  exists  from  the  time  of  the  injury  to  the  onset 
of  unconsciousness.  This  period  of  consciousness  may  be  pre- 
ceded by  the  temporary  or  prolonged  unconsciousness  of  con- 
cussion.    Unconsciousness   in  cases   of  intracranial  hemorrhage 


20 


FRACTURES    OF    THE    SKULL 


is  due  to  an  increase  of  the  intracranial  pressure  caused  bv  the 
presence  of  free  blood.  An  interval  of  consciousness  exists  in 
these  instances  in  from  one-half  to  two-thirds  of  all  cases.  In 
the  cases  of  hemorrhage  which  occur  without  an  interval  of 
consciousness  (unconsciousness  coming  on  immediately  upon 
the  receipt  of  the  injury)  it  must  be  that  the  injury  is  so  severe 
that  the  unconsciousness  caused  by  the  concussion  and  lacera- 
tion of  the  brain  is  continuous  with  the  unconsciousness  from 
hemorrhage.  The  unconsciousness  of  concussion  is  continued 
over  into   the   coma  of  compression.     The   duration   of   the   in- 


Fig.  2. — Fracture  of  skull  wilh  uiiddle 
meningeal  lieniorrhage.  Compression  of 
brain  bv  blood. 


Fig.  3. — Fracture  of  skull  with  de- 
pressed fragments  Compression  of  brain 
by  bone. 


terval   of  consciousness   mav   vary   within   very   wide   limits;   it 
may  be  a  few  moments,  it  may  be  three  months. 

The  sources  of  intracranial  hemorrhage,  whether  from  the 
middle  meningeal  artery  (see  Fig.  4)  or  its  branches  (see  I'^ig. 
5),  from  the  middle  cerebral  arteries,  from  the  veins  of  the  pia 
mater,  from  the  sinuses  of  the  brain,  or  from  lacerated  brain- 
tissue,  can  not  be  easily  differentiated  short  of  operative  pro- 
cedure. There  is  one  condition  which  is  not  to  be  overlooked 
in  connection  with  the  question  of  hemorrhage — namely,  the 
period    of    semiconsciousness    which    sometimes    follows    concus- 


EXTRADURAL    HHMOKRIIAC.E; 


21 


sion  and  laceration,  and  gives  rise  to  the  suspicion  of  some  more 
serious  gross  lesion.  To  illustrate :  A  young  girl  received  a 
severe  blow  upon  the  head.  A  true  period  of  unconsciousness 
followed.  There  were  no  external  evidences  of  hemorrhage. 
Convulsive  movements,  deviation  of  the  eyes,  and  disturbance 
of  the  pupils  were  absent.     The  breathing  was  regular  and   of 


KuJ/ture  on.  larger  scale  i 
^  l^laek  bristle  tn  Lumen. 
^Sji^r       of  artery. 


ddle  menitic/ 
fiosL  branch. 


Fig.  4. — Frontal  section  of  skull. 
Middle  meningeal  hemorrhage.  The 
dura  bulges  inward  toward  skull  cavity 
(diagram). 


Fig.  5. — A  case  of  rupture  of  middle  men- 
ingeal artery.  Preparation  of  dura  viewed 
from  outer  side  (Warren  Museum). 


Fig.  6. — Splintering  of  inner  table;  cross-sections;  diagrammatic:  a,  Usual  form  of 
punctate  fracture  ;  b,  shows  that  a  linear  fracture  may  be  much  more  extensive  internally 
than  externally. 


normal  character.  Notwithstanding  the  absence  of  other  un- 
toward symptoms,  complete  consciousness  did  not  return  for 
a  number  of  days  or  even  of  weeks.  In  such  a  case,  after  a 
number  of  days  the  question  naturally  presents  itself,  Have 
we  not  to  do  with  a  hemorrhage,  and  should  not  trephining 
be   considered?     The    absence    of    all    symptoms   excepting   the 


Fig.  7. — Case  of  compound  depressed  fracture  of  the  frontal  bone.     Note  extent  of  depression. 
Recovery  (Harrington). 


Fig.  8. — Normal  skull.     Note  relations  of  facial  bones  in  connection  with  figs.  15  and  17. 

22 


THE    I'RACTURK    OF    THE    SKUIJ.  23 

unconsciousness  should  lead  to  the  suspicion  that  we  have  to 
do  with  a  mental  state  rather  than  with  a  gross  lesion.  Ilysteroid 
semiconsciousness  (Walton)  supervening  upon  a  blow  is  not 
to  be  mistaken  for  the  deepening  unconsciousness  which  in- 
dicates hemorrhage. 

Subarachnoid  Serous  Exudation  (Cerebral  Edema). — A 
severe  blow  upon  the  head,  with  or  without  fracture  of  the  skull, 
may  result  in  a  local  bruising  and  in  congestion  and  swelling 
of  the  brain-tissue,  with  serous  exudation  into  the  subarachnoid 
space,  either  with  or  without  edema  of  the  brain-substance. 
If  this  accumulation  of  fluid  occurs  over  the  motor  area,  localized 
symptoms,  as  if  of  hemorrhage,  may  appear.  The  lesion  is 
usually  self-limited,  the  resulting  paralysis  disappearing  in  the 
course  of  a  few  days.  The  careful  observation  of  the  onset 
and  sequence  of  the  signs  of  compression  is  of  the  very  greatest 
importance,  for  it  is  by  a  proper  interpretation  of  these  localizing 
symptoms  that  the  surgeon  is  led  to  operate,  and  then  is  enabled 
to  remove  the  compressing  blood-clot  or  the  depressed  fragment 
of  bone. 

THE  FRACTURE  OF  THE  SKULL 
Whether  the  wound  of  the  bone  is  compound  or  simple,  open 
or  closed,  is  of  comparatively  little  importance,  because  of  the 
very  general  recognition  and  employment  of  aseptic  and  anti- 
septic methods.  A  knowledge  of  the  nature  of  the  fracture 
will  help  in  determining  the  injury  to  the  brain.  If  there  is  a 
perforating  fracture,  or  if  the  fragments  are  comminuted  or 
depressed,  then  it  is  highly  probable  that  a  tremendous  or  sharply 
localized  force  has  been  exerted  upon  the  bone,  and  that,  in  con- 
sequence, the  injury  to  the  underlying  brain  is  serious.  It  is 
a  generally  accepted  fact  that  the  skull  may  be  simplv  contused 
and  the  great  lateral  sinus  ruptured,  with  resulting  fatal  hemor- 
rhage. It  is  likewise  true  that  the  bone  may  present  but  a  fissure, 
but  if  that  fissure  crosses  the  middle  meningeal  arter}^  or  anv  of  its 
branches,  they  may  be  torn  across  (see  Figs,  i  and  2)  and  the 
consequent  hemorrhage  and  associated  intracranial  pressure  will 
prove  disastrous  unless  checked  bv  surgical  interference.  On 
the  other  hand,  the  bone  in  the  frontal  region  may  be  greatly 


24 


FRACTURES    OF    THE    SKULL 


Fig.  9. — Depressed  iraclure  of  frontal  bone  from  outside,  showing  depression  of  fragments 
(Warren  Museum,  specimen  7951). 


Fig.  10. — Same. as  figure  9  ;   inner  surface  from  within  ;   sliows  excess  of  bone-loiination. 


THE    FRACTURE    OF    THE    SKULU 


25 


Fig.    II. — Depressed   fracture  of  right   frontal   bone:   a,  Point   toward   vertex;   b,  anterior 
corner;  c,  lower  outer  end  (Warren  Museum,  4721). 


Fig.  12. — Same  from  within  ;  letters  as  in  figure  11.     Fracture  shows  depression  without  much, 
new  bone-formation  (Warren  Museum,  4721). 


26 


FRACTURES    OF    THE    SKULL 


damaged,  literally  crushed,  and  yet  no  grave  symptoms  arise 
(see  Fig.  7).  The  extent  of  the  bone-lesion  is,  however,  of  the 
greatest  importance. 

Fractures  of  the  Vault  of  the  Skull  (see  Fig.  9). — Fractures 
of  the  vault  of  the  skull  without  involvement  of  the  base  are 
much  more  unusual  than  is  generally  supposed.  More  than 
two-thirds  of  all  fractures  of  the  vault  are  associated  with  frac- 
ture of  the  base  of  the  skull  (see  Figs.  9,  10,  11,  12).  Evidences 
of  fracture  of  the  vault  are  determined  by  sight  and  touch.  A 
wound  in  the  scalp  may  disclose  the  fractured 
bone.  Whether  this  is  a  mere  fissure  or  a  single 
or  a  comminuted  fracture,  whether  depressed 
or  not  below  the  general  surface  of  the  normal 
skull,  can  be  determined  only  by  careful  in- 
spection. A  fissure  of  the  bone  may  be  diffi- 
cult of  recognition.  It  must  be  remembered 
in  this  connection  that  blood  can  not  be  wiped 
from  a  fissure,  whereas  from  the  normal  suture 
lines  it  can  readily  be  wiped  away.  Blood  may 
be  seen  escaping  through  a  fissure.  Torn  peri- 
osteum must  not  be  confused  with  a  fissure  of 
the  bone. 

A  hematoma  of  the  scalp  may  suggest  a  de- 
pressed fracture  of  the  skull  (see  Fig.  13).  The 
center  of  the  blood-tumor  is  soft ;  the  edges  are 
edematous  and  hard.  If  the  finger  be  pressed 
firmly  into  the  soft  center,  an  intact  skull 
generally  will  be  felt.  The  uniform  edge  of  a 
hematoma  is  unlike  the  irregular  jagged  edge  of  a  fracture.  It  is 
sometimes  impossible  to  distinguish  between  a  hematoma  and  a 
fracture  of  the  skull.  The  symptoms  of  general  disturbance  are 
usuallv  more  marked  and  prolonged  in  the  case  of  a  fracture  of 
the  skull  than  when  only  a  hematoma  is  present. 

Fracture  of  the  Base  of  the  Skull  (see  Fig.  14). — It  is  not 
uncommon  to  discover  that  what  in  the  vault  appears  to  be 
a  simple  fissure  continues  down  to  and  involves  the  base  of 
the  skull.  Fractures  of  the  base  of  the  skull  are  usually  re- 
garded,   and   rightly  so,    as  more   serious  than  fractures  of  the 


Fig.  13.— No  frac- 
ture of  skull.  Hemato- 
ma of  scalp,  the  depress- 
ed center  and  firm  edge 
of  which  often  simulate 
fracture. 


SYMPTOMS    OK    FRACTURE    OK    THIi    BASE  27 

vault.  A  greater  trauma  being  necessary  to  cause  the  fracture, 
the  cerebral  disturbance  is  more  pronounced  and  vital  parts  are 
endangered.  These  fractures  of  the  base  often  open  into  cavities 
which  it  is  impossible  to  keep  surgically  clean — namely,  the 
cavities  of  the  nasopharynx  and  the  ear.  The  danger  of  septic 
infection,  therefore,  in  such  fractures  is  very  great.  About 
eighty-five  per  cent,  of  basic  fractures  originate  in  the  vault — 
i.e.,  are  caused  by  an  extension  of  a  linear  fracture  of  the  vault 
to  the  base.  A  few  basic  fractures  are  due  to  forces  acting 
from  below  and  thus  causing  a  penetration  of  the  base  of  the 


Fig.  14. — Punctate  fracture  entering'  posterior  fossa.     From  the  punctate  depression  a  line 
of  fracture  extends  downward  and  baclcward  (Warren  Museum,  specimen  965). 

skull  by  other  bones.  The  facial  bones  may  be  forced  up  into 
the  anterior  fossa  (see  Fig.  15).  The  articular  process  of  the 
inferior  maxillary  bone  may  be  pushed  up  through  the  glenoid 
fossa  of  the  temporal  bone  (see  Fig.  16)  into  the  middle  fossa 
by  a  blow  upon  the  chin,  particularly  if  the  jaw  is  relaxed.  The 
vertebral  column  may  be  forced  up  into  the  posterior  fossa 
through  a  fracture  of  the  occiput. 

Symptoms  of  Fracture  of  the  Base. — Hemorrhage  may  take 
place  from  the  ear,  from  the  nose,  from  the  mouth  or  be  noticed 
under  the  conjunctivae.  Occasionally  blood  is  seen  in  all  four 
situations.     Hemorrhage    may    occur    beneath    the    pharyngeal 


28 


FRACTURES    OF    THE    SKULL 


mucous  membrane.  Escape  of  cerebrospinal  fluid  from  the 
ear  and  nose  may  be  noticed.  Brain-tissue  sometimes  escapes 
from  the  skull  and  is  seen  lying  in  the  external  auditory  meatus 
or  near  a  wound  which  communicates  with  the  fracture  of  the 
skull.  Injuries  may  occur  to  the  third,  fifth,  seventh  and  eighth 
nerves.  Associated  with  these  local  signs  may  be  the  general 
signs  of  concussion  or  laceration  of  the  brain. 

If  the  orbital  plate  of  the  frontal  bone  is  broken,  blood  will 
gravitate  into  the  orbit;  ecchymosis  of  the  lids  and  subconjunc- 
tival hemorrhage  will  appear.  There  may  be  greater  tension 
of  the  eyeball  upon  the  affected  side,  detected  by  palpating 
the  globe  through  the  closed  lid.     Subconjunctival  hemorrhage 

may  appear  from  a  fracture  of 
the  malar  or  superior  maxillary 
bones. 

If  the  cribriform  plate  of  the 
ethmoid  is  fractured,  hemorrhage 
from  the  nose  will  occur  (see  Fig. 
17).  Impairment  of  the  sense  of 
smell  may  exist  if  the  olfactory 
nerves  become  involved  in  the 
fracture.  Blood  may  trickle 
from  a  fracture  of  the  base  into 
the  pharynx,  be  swallowed,  and 
later  vomited.  Epistaxis,  of  course,  may  be  due  to  a  blow  upon 
the  face  without  fracture  of  the  base.  If  inspection  discloses  a 
broken  nose  or  ecchymosis  of  the  face  or  the  skin  of  the  fore- 
head, it  is  very  probable  that  the  minor  accident  has  occurred. 

Most  fractures  of  the  base  involve  the  middle  fossa.  If  the 
petrous  portion  of  the  temporal  bone  is  fractured,  several 
important  signs  appear.  If  the  tympanum  is  torn,  hemor- 
rhage from  the  external  auditory  meatus  is  sure  to  follow.  If 
this  hemorrhage  is  continuous,  it  is  significant ;  if  it  is  trifling 
and  temporary,  it  is  probably  unimportant  and  may  be  local. 
Cerebral  tissue  may  escape  from  the  nose,  thus  establishing 
the  seat  of  the  lesion.  Cerebrospinal  fluid  may  likewise  escape 
from  the  ear.  Cerebral  tissue  may  also  appear  at  the  external 
auditory    meatus.     Any    of   these    signs    is   conclusive   evidence 


Fig.  15. — Fracture  of  base  of  skull  ; 
impaction  of  nasal  and  part  of  ethmoid 
bones,  which  project  into  the  interior  of 
the  cranium.  Male,  aged  twenty-eight ; 
diagnosis,  fracture  of  nose.  Died  of  men- 
ingitis (after  Helferich). 


SYMPTOMS  OF  FRACTURE  OF  THE  BASE 


29 


that  the  base  of  the  skull  is  fractured  and  that  there  is  a  lesion 
of  the  brain.     Lesions  of  the  facial  (seventh)  and  auditory  (eighth) 


Posterior  nares. 


Glenoid  fossa. 

External  pterygoid 
plate. 


Fig.  i6.-Showing  thinness  of  tlie  roof  of  the  glenoid  fossa,  which  is  occasionally  broken  by 
the  condyloid  process  of  the  inferior  maxilla  when  a  blow  is  received  on  the  jaw. 


Frontal  sinus. 


Sphenoidal  sinus.        Cribriform  plate. 
Fig.  17.— Median  section.     Anterior  portion  of  skull,  showing  thinness  of  the  ethmoid  plate, 
which  alone  separates  the  cavities  of  nose  and  skull. 

-nerves  lying  within  the  bones  occur.     Lesions  are  likewise  re- 
ported of  the  fifth  nerve,  because  of  its  lying  upon  the  fractured 


30 


FRACTURES    OF    THE    SKULL 


petrous  portion  of  the  temporal  bone.  Subconjunctival  hemor- 
rhage may  appear,  owing  to  the  blood  working  its  way  forAvard 
through  the  sphenoidal  fissure  and  the  optic  foramen.  A  primary 
profuse  watery  discharge  from  the  nose  or  the  ear  is  probably 
cerebrospinal  fluid.  A  watery  discharge  appearing  late  after 
such   an   injury   is  likely  to  be   serum  from   a  blood-clot.     The 


Foramen 

ovale. 

Foramen 

spincsum. 

Petrous 

portion 

temporal 

bone. 

Lateral 

sinusfossa 


Fig.  i8. — The  three  fossae  of  the  base  of  the  skull  viewed  from  above. 


optic  nerve  may  be  involved  in  the  injury  with  resulting  blind- 
ness. 

If  the  posterior  fossa  (see  Fig.  i8)  is  involved  in  the  fracture, 
there  may  be  hemorrhage  into  the  pharynx.  Ecchymosis  under 
the  pharyngeal  mucous  membrane  may  be  present  without 
actual  rupture  of  the  mucous  membrane.  A  fullness  may  be 
detected  by  palpation  in  the  posterior  wall  of  the  pharynx,   if 


UNCONSCIOUSNESS.  31 

the  hemorrhage  there  is  considerable.  Ecchymosis  just  in  front 
of  the  mastoid  process,  or  a  hematoma  and  puffy  swelHng  over 
the  seat  of  the  fracture,  may  determine  its  location. 

Unconsciousness  Resulting  from  Other  than  Surgical 
Causes. — There  are  certain'  conditions  associated  with  loss 
of  consciousness  and  delirium  which  must  be  differentiated 
from  traumatic  intracranial  lesions.  These  conditions  are  (a) 
the  coma  from  opium-poisoning;  (b)  the  unconsciousness  in 
uremia;  (c)  the  loss  of  consciousness  from  apoplexy;  (d)  alcoholic 
coma;   and  (e)  hemorrhagic  internal  pachymeningitis. 

Coma  from  Opium-poisoning:  The  patient  can  be  aroused 
unless  the  poisoning  is  extremely  profound,  and  can  be  made 
to  understand,  and  will  even  reply  to  an  inquiry.  The  face 
at  first  is  pale,  later  it  is  flushed  and  swollen.  The  skin  is  warm 
and  moist.  The  respiration  is  slow.  The  temperature  is  sub- 
normal. The  pulse  is  slow  and  full.  The  pupils  are  strongly, 
immovably,  and  symmetrically  contracted.  The  reflexes  may 
be  absent. 

The  Unconsciousness  in  Uremia :  The  patient  can  not  be  aroused. 
The  face  is  white,  edematous,  and  puffy.  The  breath  has  a 
sweetish  odor.  The  respiration  is  frequent  and  irregular.  The 
temperature  is  normal.  The  pulse  is  rapid.  The  pupils  are 
dilated  and  sluggish.     The  urine  usually  contains  albumin. 

The  Unconsciousness  from  Apoplexy:  The  patient  can  not  be 
aroused.  The  respiration  is  slow,  irregular,  and  stertorous. 
The  temperature  is  subnormal  at  first;  if  a  fatal  termination 
is  probable,  the  temperature  is  high.  The  pupils  are  dilated. 
Unilateral  paralysis  of  the  face  and  the  extremities  usually 
is  present.  The  affected  extremities  are  warmer  than  those 
of  the  other  side.  The  limbs  may  be  relaxed,  but  in  watching 
the  patient  carefully  evidences  of  hemiplegia  will  appear.  The 
history  of  previous  hemorrhages  may  be  discovered  pointing 
to  hemorrhagic  internal  pachymeningitis. 

Alcoholic  Coma:  The  patient  can  be  aroused  by  pressure 
upon  the  supra-orbital  nerves — sometimes,  however,  with  great 
difficulty.  The  breath  may  be  alcoholic.  The  face  is  flushed. 
The  respiration  is  regular.  The  pulse  is  rapid.  The  tempera- 
ture  is  normal   or  low.     The   pupils  are   normal.     There   is   an 


32  FRACTURES    OF    THE    SKULL 

absence  of  the  positive  signs  of  a  cerebral  lesion.  The  tempera- 
ture in  cerebral  laceration  is  elevated.  Alcoholic  delirium  will 
present  an  elevated  temperature,  but  along  with  the  elevated 
temperature  of  a  lacerated  brain  there  will  be  symptoms  char- 
acteristic of  a  damaged  brain. 

Hemorrhagic  Internal  Pachymeningitis:  The  occurrence  of 
apoplectic  seizures  during  the  course  of  this  disease  makes  it 
important  that  it  be  recognized  in  connection  with  the  distinctly 
traumatic  hemorrhages  under  consideration.  The  character- 
istic course  shows  an  acute  diffused  affection  of  the  brain,  usually 
in  an  elderly  man  and  with  severe  symptoms.  An  acute  attack 
is  followed  by  a  fair  recovery  and  by  intervals  of  comparative 
health.  During  these  intervals  of  comparative  health  the  pa- 
tient has  some  headache,  slight  diminution  of  intelligence,  im- 
pairment of  memory,  drowsiness,  partial  paralysis  of,  the  limbs 
(usually  unilateral),  disturbances  of  speech,  and  sudden  mental 
excitement  without  cause  mixed  with  symptoms  of  paralytic 
dementia.  Evidences  of  a  sudden  and  increasing  compression 
are  headache,  drowsiness,  loss  of  consciousness,  some  fever,  a 
pulse  of  compression,  and  sometimes  initial  symptoms  of  ir- 
ritation. The  diagnosis  is  assisted  by  the  etiology  and  history 
of  the  case.  In  middle  meningeal  hemorrhage  a  blow  is  neces- 
sary to  cause  alarming  symptoms,  whereas  in  hemorrhagic 
pachymeningitis  a  very  trivial  injury  or  none  at  all  is  common. 
The  longer  duration  of  the  sA^mptoms  would  help  to  decide  against 
middle  meningeal  hemorrhage.  There  is  often  a  rigiditv  of 
the  limbs  in  hemorrhagic  pachymeningitis  which  is  absent  in 
middle  meningeal  hemorrhage  cases. 

When  called  upon  to  see  a  case  of  head-injury,  it  must  be 
remembered  that  the  lesion  can  not  always  be  determined  by 
the  first  observation  of  the  patient.  It  is  absolutelv  necessary 
that  there  be,  upon  the  part  of  the  physician,  a  clear  under- 
standing of  the  method  of  onset  and  the  sequence  of  symptoms 
from  the  time  of  the  receipt  of  the  injury.  Isolated  signs  are  of 
less  importance  than  relative  symptoms. 

Examination  of  the  Patient. — The  following  comprehen- 
sive method  of  examining  an  individual  who  has  received  a 
severe  injury  to  the  head  should  be  carefully  followed,  bearing 


EXAMINATION    OF    THE    PATIENT  33 

in  mind  always  the  possible  cranial  and  intracranial  lesions, 
and  remembering  that  a  fracture  of  the  skull  as  such  is  of 
secondary  importance,  that  an  injury  to  the  intracranial  vessels 
is  serious,  and  that  a  lesion  of  the  brain  itself  is  most  important. 

If  with  brain  symptoms  there  is  no  visible  injury  to  the  skull, 
the  head  should  be  shaved  to  facilitate  careful  examination. 
Acute  localized  pain  suggests  the  seat  of  fracture. 

When  was  the  accident?  How  much  time  has  elapsed  between 
the  accident  and  the  first  accurate  observation? 

What  was  the  accident?     Was  it  a  fall  or  a  blow? 

What  is  the  age  of  the  patient?  Are  the  arteries  atheroma- 
tous, and  therefore  easily  ruptured  by  trivial  injury?  Is  it 
the  skull  of  a  child — which  is  softer  and  less  brittle  than  that 
of  an  adult? 

What  was  the  condition  of  health  previous  to  the  accident? 
Was  it  poor — suggestive  of  kidney-disease  and  uremia?  Was 
the  man  alcoholic,  or  is  the  present  condition  masked  by  alcohol 
taken  subsequent  to  the  accident? 

The  General  Condition  of  the  Patient:  If  unconsciousness 
is  present,  was  its  onset  immediate,  or  was  there  a  lucid  interval 
after  the  accident?  Has  the  unconsciousness  been  continuous, 
and  is  it  deepening  or  lessening? 

What  are  the  evidences  of  shock  present?  W^hat  is  the  con- 
dition of  the  pulse,  of  the  respiration,  of  the  skin?  What  is 
the  temperature  taken  in  the  rectum?  Has  vomiting  occurred? 
Have  there  been  involuntary  dejections?  Has  there  been  in- 
voluntary micturition? 

The  Local  Condition :  The  wound  of  the  scalp  or  skull  or  brain 
may  be  evident.  If  hemorrhage  is  present,  what  is  its  source? 
Is  it  from  the  nose,  the  mouth,  the  ear,  or  into  the  orbit?  When 
did  the  hemorrhage  occur?  What  was  its  amount?  Was  it 
continuous  or  not?  Palpation  should  be  made  of  the  skull, 
the  neck,  the  face,  the  spine,  the  jaw,  and  the  temporo-maxil- 
lary  joint. 

Are    any    localizing    signs    present?     What    is    the    condition 
of  the  pupils,  and  of  the  muscles  of  the  face,  the  arms,  and  the 
legs?     What  is  the  condition  of  the  reflexes  and  of  the  respira- 
tion?    Does  hemiplegia,  either  partial  or  complete,  exist? 
3 


34  FRACTURES    OF    THE    SKULL 

Finally,  the  whole  bodv  should  be  examined  systematically 
for  any  other  injuries  than  those  to  the  head  and  to  the  nervous 
system.  Associated  injuries,  if  discovered,  may  assist  in  in- 
terpreting the  nature  of  the  cerebral  injury. 

A  diagnosis  must  be  based  upon  all  available  evidence.  One 
will  have  to  consider  concussion  and  laceration  of  the  brain 
and  pressure  upon  the  brain  by  serum,  blood,  and  bone.  The 
important  signs  to  be  studied  in  diagnosis  are  the  different  as- 
pects of  unconsciousness;  the  relative  and  actual  conditions 
of  the  respiration,  pulse,  and  temperature ;  the  occurrence  of 
hemorrhage;  restlessness  and  nmscular  twitching;  localizing 
signs  of  pressure.  If  the  symptoms  are  not  positive,  if  there  is 
no  history  of  trauma,  if  the  history  of  a  lucid  interval  preceding 
unconsciousness  is  doubtful,  or  if  there  is  no  history  at  all,  then 
the  diagnosis  will  be  most  difficult.  It  is  when  positive  symp- 
toms are  absent  that  one  must  particularly  consider  those  con- 
ditions already  mentioned  in  which  coma  is  a  prominent  sign — 
namely,  opium-poisoning,  uremia,  apoplexy,  alcoholism. 

General  Observations. — An  unconscious  man  having  a 
scalp  wound  and  a  breath  smelling  of  liquor  is  not,  necessarily, 
drunk.  He  may  have  an  intracranial  lesion.  Multiple  lesions 
may  be  present  in  any  case.  A  diffuse  lesion  may  obscure  a 
localized  lesion.  Not  only  must  the  location  of  a  lesion  be  deter- 
mined, but  also  its  character,  if  possible.  The  symptoms  must 
be  recorded  in  the  order  of  their  appearance.  The  manner 
in  which  various  symptoms  develop  should  be  noted.  The 
danger  to  the  brain  is  greatest  in  perforating  and  sharply  de- 
pressed fractures.  Slight  fissures  may  be  associated  with  ex- 
tensive hemorrhages.  Great  comminution  of  bone  may  be 
devoid  of  much  danger.  In  cases  of  compound  fracture  fissures 
apparently  closed  afford  the  possibility  of  cerebral  and  meningeal 
infection  through  dirt  having  entered  when  the  fissure  was  open. 

Unconsciousness  and  a  superficial  head-lesion,  with  or  with- 
out fracture  of  the  skull,  must  make  one  suspicious  of  an  intra- 
cranial lesion.  An  immediate  loss  of  consciousness  indicates 
a  diffused  contusion  or  concussion  of  the  brain.  If  the  primary 
unconsciousness  is  prolonged,  probably  hemorrhage  has  occurred, 
or  possibly  a  serous  exudation  with  its  resulting  pressure  upon 


TREATMENT  Or'  FRACTURKS  OF  THE  SKULL         35 

the  brain.  If  there  is  a  conscious  interval  preceding  the  uncon- 
sciousness, a  hemorrhage  is  probable.  Momentary  unconscious- 
ness means  concussion.  Recurring  unconscious  periods  indicate 
hemorrhage.  Deepening  unconsciousness  indicates  increasing 
intracranial  pressure — probably  hemorrhage.  Immediate  pro- 
found unconsciousness  suggests  hemorrhage  from  the  rupture 
of  an  intracranial  sinus. 

The  temperature  in  all  intracranial  lesions  is  usually  slightly 
above  normal.  Intoxication  and  shock  depress  the  tempera- 
ture. In  a  small  intracranial  hemorrhage  there  will  be  a  slight 
rise  of  temperature,  perhaps  to  99°  F.,  following  the  initial  drop 
a  few  hours  after  the  injury.  In  cerebral  laceration  one  finds 
a  higher  initial  temperature  than  in  hemorrhage,  and  in  fatal 
cases  the  temperature  remains  elevated.  If  the  temperature 
rises  quickly  and  early,  a  considerable  laceration  is  present; 
if  after  several  hours  of  unconsciousness  the  temperature  re- 
mains about  99°  or  99.5°  F.,  there  is  probably  a  hemorrhage 
rather  than  a  severe  direct  lesion;  if,  on  the  other  hand,  the 
temperature  rises  higher,  there  is  a  cerebral  lesion,  alone  or 
associated  with  a  hemorrhage.  If  the  temperature  does  not 
rise  very  high  and  advances  rather  slowly,  there  is  a  contusion 
or  a  concussion  with  slight  laceration  or  a  slight  hemorrhage. 
A  slow,  full  pulse  with  stertorous  respiration  suggests  pressure; 
it  may  be  from  extradural  hemorrhage.  Early  and  very  slow 
respiration  is  associated  with  pressure  upon  the  medulla. 

Paralysis  of  the  limbs  and  the  face  is  characteristic  of  serous 
exudation,  hemorrhage,  or  bony  pressure.  Irregular  muscular 
contractions  suggest  laceration  of  motor  areas.  Mental  dis- 
turbance may  be  due  to  cerebral  lesions.  That  brain-tissue 
escapes  from  the  ear  does  not  necessarily  signify  that  the  patient 
will  not  recover.  Fractures  of  the  base  of  the  skull  occur  with- 
out marked  symptoms  and  recover  without  the  necessity  of 
operation. 

Treatment. — There  are  cases  of  injury  to  the  skull  so  serious 
that  it  is  evident  that  operation  will  be  of  no  avail.  There 
are  cases  of  simple  concussion  in  which  only  careful  nursing 
is  demanded.  There  is  a  large  and  increasing  number  of  serious 
head-accidents    in   which    operative    interference    will    prove    of 


36  FRACTURES    OF    THE    SKULL 

great  value.  The  collapse  from  shock  may  be  well-nigh  com- 
plete, but  restorative  measures  are  not  to  be  neglected  upon 
this  account.  If  hemorrhage  is  suspected,  stimulation  of  the 
circulation  must  be  very  guarded.  The  patient  should  be  placed 
norizonlally,  with  the  head  slightly  raised,  and  kept  quiet.  The 
whole  bodv  should  be  wrapped  in  warm  blankets.  Warm  water- 
bottles  should  be  put  on  the  outside  of  the  bed  about  the  patient 
not  next  the  skin,  one  at  each  foot,  three  along  each  side  of  the 
body.  The  water  in  these  bottles  should  be  comfortably  warmed 
— 110°  F.  Hot  water  is  never  to  be  used.  Patients  under 
these  circumstances  are  insensible  to  heat,  and  severe  burning 
of  the  skin  may  occur  if  very  hot  water  is  used  in  the  bottles. 

If  there  are  no  indications  for  immediate  operation,  and  local- 
izing symptoms  are  absent,  the  patient  is  to  be  treated  sympto- 
matically.  The  pulse  is  to  be  carefully  watched  to  detect  varia- 
tions in  strength,  rate,  and  rhythm.  The  character  and  fre- 
quencv  of  the  breathing  are  to  be  likewise  noted.  Gentle  stimu- 
lation subcutaneously  by  sulphate  of  strychnin  (^^^  of  a  grain), 
administered  as  needed,  will  often  steady  a  pulse  remarkably. 
A  special  nurse  or  an  intelligent  watcher  should  be  with  the 
patient  constantly,  to  note  any  localizing  signs  of  pressure,  such 
as  twitching  of  the  muscles  of  the  face  or  limbs  and  variations 
in  the  pupil,  to  record  movements  of  the  limbs,  and  to  make 
hourly  observations  of  the  pulse,  temperature,  and  respiration, 
and  any  variation  in  consciousness.  These  observations  will 
be  of  inestimable  value  in  determining  diagnosis,  prognosis, 
and  treatment. 

The  various  cavities  exposing  the  brain  to  infection  should 
be  cleansed. 

The  Nose. — The  nose  should  be  douched  with  boric  acid  solu- 
tion (1:30),  and  plugs  of  sterilized  absorbent  cotton  should 
be  placed  in  each  nostril. 

The  Ear. — The  ear  should  be  douched  with  boric  acid  solu- 
tion (1:30),  and  dried  carefully  with  small  wisps  of  cotton. 
Boric  acid  powder  should  then  be  blown  gently  into  the  external 
auditory  meatus.  A  bit  of  sterilized  gauze  or  absorbent  cotton 
may  be  left  in  the  meatus. 

The  Scalp. — The  directions  for  cleansing  the  scalp  pertain  to 


TREATMENT  OF  FRACTURES  OF  THE  SKULL 


37 


cases  with  or  without  scalp  wounds  associated  with  important 
cerebral  symptoms.  The  whole  scalp  should  be  shaved,  scrubbed 
with  hot  water  and  soap,  with  chlorinated  soda  solution  (i  :2oj, 
with  boiled  water,  and  then  with  corrosive  sublimate  solution 
(i :  looo),  and  covered  with  a  dressing  of  sterilized  gauze  that 
has  been  moistened  in  a  solution  of  corrosive  sublimate  (i  :5ooo). 
The  wound  of  the  soft  parts  should  be  carefully  irrigated  with 
sterilized  salt  solution,  and  sponged  and  swabbed  with  great 
care  with  corrosive  sublimate  solution  (1:5000).  The  swabs 
used  should  be  tiny  ones,  so  as  to  reach  to  the  smallest  recesses 
of  the  wound.  Corrosive  sublimate 
solution  should  not  be  allowed  to 
touch  the  brain-tissue. 

The  Mouth. — Thorough  cleans- 
ing, with  corrosive  sublimate  solu- 
tion (i :  3000),  of  the  teeth  and 
tongue  and  all  the  folds  of  the  mu- 
cous membrane  about  the  lower 
and  upper  jaws  is  important.  The 
swabbing  of  the  tonsils  and  the 
posterior  pharyngeal  wall,  the  care 
of  the  nose  and  the  ear, — these  pro- 
cedures will  reduce  to  a  minimum 
the  chances  of  infection .  The  nose 
and   mouth  will  require  constant 

attention.  The  ear  will  require  at  least  daily  cleansing.  The 
frequency  of  the  cleansing  required  will  depend  verv  largely  upon 
the  amount  of  moisture  and  discharge  from  the  part  involved.  If 
the  packing  of  cotton  soon  becomes  moistened,  the  douching  should 
be  repeated,  and  fresh,  dry  packing  should  replace  the  old. 

If  there  is  great  restlessness,  it  may  be  necessary  to  restrain 
the  patient,  that  he  may  not  harm  himself.  This  is  done  bv 
means  of  a  sheet  folded  and  passed  about  the  bed  and  body 
of  the  patient. 

Operative  interference  is  demanded  in  penetrating  or  sharplv 
depressed  fractures,  in  all  compound  fractures,  and  in  all  simple 
fractures  with  symptoms  of  intracranial  hemorrhage  increasing  in 
severity  or  distinctly  localized  (see  Figs.  19,  20,  21).     A  localized 


Fig.  19. — Sites  where  extradural  hemor- 
rhage is  usually  found. 


38 


FRACTURES    OF    THE    SKULL 


compound  depressed  fracture  of  occiput  over  the  cerebellum  with- 
out serious  symptoms  may  be  an  exception  to  this  statement. 
Operation  should  be  undertaken  in  these  cases  for  three  distinct 


Fig.  20. — Location  of  anterior  branch  of  middle  meningeal  artery.  Draw  a  line  from 
the  glabella  backward  (a  rf),  parallel  to  the  line  b  c,  from  the  lowejr  edge  of  the  orbit  through 
the  external  meatus.  Line  from  glabella  to  mastoid,  a  e.  From  the  middle  of  this  last  line, 
a  line  drawn  perpendicular  to  it  will  intersect  the  line  a  rf  at  about  the  site  of  the  artery.  A 
line  running  from  the  front  of  the  mastoid  perpendicular  to  the  line  b  c  intersects  a  a' at  about 
the  site  of  the  posterior  branch. 


Fig.  21. — Perpendicular  lines  from  the  mastoid  and  from  just  in  front  of  the  ear  include  the 
motor  area  of  the  central  convolutions.     The  fissure  of  Rolando  is  shown. 


reasons:  to  insure  cleanliness,  to  elevate  and,  if  necessary,  re- 
move bony  fragments,  and  to  check  hemorrhage.  The  details  of 
operative  treatment  must  necessarily  be  omitted. 


LATER   RESULTS   OF   FRACTURE   OF   THE   SKULL  39 

All  cases  of  injury  to  the  head,  even  cases  of  simple  nonde- 
pressed  fracture  of  the  skull  without  symptoms,  are  to  be  watched 
with  great  care  by  trained  observers  for  at  least  one  month 
following  the  accident,  and  then  are  to  be  seen  at  intervals  for 
many  months  afterward.  The  reason  for  this  prolonged  ob- 
servation is  that  meningeal  hemorrhage  may  develop  in  the 
immediate  future,  and  that  after  an  interval  of  months  a  brain- 
abscess  may  manifest  its  presence. 

In  fracture  of  the  base  with  pronounced  symptoms,  drain- 
age of  the  fossa  involved,  whether  anterior,  middle,  or  posterior, 
should  be  considered.     It  has  occasionally  been  of  service. 

Prognosis. — The  prognosis  of  head-injuries  is  the  prognosis 
of  their  complications  and  sequelae.  Prolonged  unconscious- 
ness is  not  usually  dangerous  in  itself.  Late  unconsciousness 
is  dangerous.  The  severity  rather'  than  the  form  of  the  lesion 
is  to  be  made  the  basis  of  prognosis.  The  temperature  is  of 
great  value  in  prognosis.  By  its  persistent  depression  the  danger 
from  primary  shock  is  gauged;  a  little  later  in  the  course  of  the 
case  the  amount  of  hemorrhage  is  judged  by  it;  later  still,  its 
rapid  and  progressive  rise  will  denote  the  magnitude  or  severity 
■of  a  meningeal  or  cerebral  lesion.  A  temperature  as  high  as 
105°  F.  is  of  grave  prognosis.  A  sudden  rise  of  temperature 
late  in  the  progress  of  a  case,  probably  due  to  a  meningitis,  or 
a  continued  subnormal  temperature  at  any  time  after  the  re- 
action from  the  primary  shock,  is  always  an  unfavorable  sign. 
Symptoms  often  change  suddenly  in  cases  apparently  doing 
well.     One's  prognosis  must,  therefore,  always  be  guarded. 


LATER  RESULTS  OF  FRACTURE  OF  THE  SKULL 
Very  little  is  known  of  these  cases  in  this  country.  Dr.  Bul- 
lard,  of  the  Boston  City  Hospital,  has  contributed  so  valuable  a 
paper  upon  this  subject  that  the  results  are  here  stated :  Seventy 
patients  were  examined  after  having  had  fracture  of  the  skull; 
37  presented  no  symptoms  when  examined  some  time  later. 
The  most  frequent  consequences  were  headache,  deafness,  dizzi- 
ness, and  inability  to  resist  the  action  of  alcohol  on  the  brain. 
Out  of  15  cases  in  which  operation  (trephining)  was  performed, 


40  INJURIES    TO    THE    HEAD 

I  2  had  no  resulting  symptoms ;  in  one  case  it  was  doubtful  whether 
the  symptoms  present  were  due  to  injury;  in  one  case  the  symp- 
toms were  slight  (headache  rare,  tension  oyer  the  wound  while 
lying  in  bed).  The  other  case  was  deaf,  but  had  no  other  trouble. 
Dr.  Bullard  concludes,  so  far  as  these  statistics  lead,  that 
those  cases  in  which  trephining  was  performed  have  shown 
much  better  results,  so  far  as  the  symptoms  previously  mentioned 
are  concerned,  than  those  in  which  no  operation  was  performed. 

CASES  OF  HEAD  INJURY 
The  following  cases,   related  in  some  detail,   illustrate  a  few 
of  the  varieties  of  injuries  to  the  head  from  a  clinical  standpoint : 

Case  I. — A  fall  upon  the  head. — No  visible  evidences  of  injuiy. — An 
interval  of  consciousness  followed  by  unconsciousness. — Localizing  signs 
of  pressure. — Diagnosis,  middle  tneningeal  hemorrhage  with  fracture 
of  skull.  —  Operation. — Fracture  and  henior?'hage  found. — Recovery. 

M.   A.   B ,  sixty-nine  years    old,  a  spinster,   fell,  upon  being 

struck  by  a  coasting-sled,  one  and  one-half  hours  previous  to  the 
examination. 

Examination. — She  does  not  know  of  the  accident  which  has  be- 
fallen her.  She  talks  coherently.  She  recognizes  her  sister.  There 
is  slight  shock.  The  pulse  is  64  and  of  fair  strength  ;  the  respira- 
tion is  16  ;  the  temperature  is  97.5°  F.  There  is  bleeding  from  the 
right  ear.  There  is  some  dry  blood  about  the  nostrils.  There  is  no 
visible  external  injury.  There  is  no  paralysis.  All  the  superficial 
reflexes  are  present.  The  pupils  are  contracted  equally  and  react  to 
light.  The  patient  is  not  very  restless,  although  she  talks  consider- 
ably and  affirms  again  and  again  that  she  is  not  hurt. 

The  ears  were  washed  out  carefully  and  treated  antiseptically. 

She  vomited  two  or  three  times  during  the  night.  She  was  quite 
restless,  moving  and  turning  in  bed.  She  slept  two  or  three  hours 
altogether.  There  were  no  evidences  of  intracranial  pressure  in  the 
morning.  At  about  noon  of  the  second  day  she  talked  a  little  inco- 
herently.    She  did  not  answer  questions  as  readily  as  in  the  morning. 

At  3  o'clock  in  the  afternoon  of  the  second  day  examination  finds 
the  pupils  equal  and  reacting  to  light.  She  understands  what  is  said 
to  her,  but  does  not  talk  coherently  or  distinctly.  There  is  almost 
complete  paralysis  of  the  right  arm.  There  is  paresis  of  the  right  leg. 
The  face  is  not  paralyzed.  The  pulse  has  increased  in  rate  to  85  and 
is  particularly  full  and  bounding.  The  knee-jerk  is  much  less  active 
upon  the  right  than  upon  the  left  side. 

At  4.30  P.M.,  one  and  one-half  hours  after  the  previous  observa- 
tion, all  the  symptoms  were  considerably  intensified.  The  face  was 
uneven,  the  wrinkles  being  most  marked  on  the  left.      The  breathing 


ILLUSTRATIVE   CASES 


41 


was  becoming  labored  and  almost  stertorous.  It  was  hard  to  arouse 
the  woman.  She  moved  the  left  arm  freely.  'I'he  right  arm  she  moved 
slightly  or  not  at  all.  There  were  no  abdominal  reflexes  active,  iileed- 
ing  from  the  right  ear  continued  to  a  slight  extent  all  day. 

A  diagnosis  of  middle  meningeal  hemorrhage  on  the  left  side  was 
made.      Immediate  operation  was  decided  upon. 

Under  ether  anesthesia  an  elliptic  incision  was  made  ujjon  the  left 
side  of  the  head,  beginning  just  in  front  of  the  ear,  and  was  carried 
up  across  the  temporal  muscle  and  down  to  the  zygoma  of  the  same 
side.  A  quarter-inch  trephine  was  used.  The  hemorrhage  was  found 
to  be  from  a  branch  of  the  middle  meningeal  artery,  and  from  within 
the  dura,  which  was  lacerated.  A  large  clot  and  much  fresh  blood 
were  lying  over  the  temporal  and  parietal  regions.  This  blood  was 
carefully  sponged  away.  The  middle  meningeal  branch  was  tied 
with  a  silk  ligature.  Gauze  wicks  were  placed  well  down  deep 
toward  the  base  of  the  skull.  The  dura  was  not  sutured.  The  bleed- 
ing vessels  of  the  diploe  were  stopped  with  wax.  The  skin  flap  was 
replaced  and  sutured,  leaving  a  small  gauze  drain  down  to  the  dura. 

The  pulse  was  poor,  and  there  was  evidence  of  considerable  shock 
at  the  conclusion  of  the  operation.  Proper  stimulation  with  strych- 
nin and  enemata  of  salt  solution 
and  brandy  had  a  good  effect. 
The  temperature  rose  to  110°  F. 
during  the  night,  but  dropped 
immediately  and  gradually  came 
to  normal. 

The  following  day  uncon- 
sciousness was  present,  the  par- 
alysis was  unrelieved,  the 
breathing  was  stertorous  and 
puffing. 

The  second  day  after  the  op- 
eration the  gauze  drain  was  re- 
moved and  two  smaller  gauze 
drains  were  inserted.  Some 
signs  of  consciousness  appear. 
She  takes  notice  of  people  com- 
ing into  the  room. 

The  fifth  day  following  the 
operation  she  notices  friends. 
The  paralysis  is  still  present. 

The  sixth  day  after  the  op- 
eration she  moves  the  right  leg 
a  little.      No  articulate  speech 

is  present.  Understands  questions  and  grunts  in  answer  to  all  ques- 
tions.     She  can  express  no  idea  in  words. 

The  tenth  day  after  the  operation  she  moves  the  right  arm.  The 
mental  condition  is  clearer. 

On  the  eighteenth  day  she  moves  the  right  leg,  and  the  arm  has 
more  power. 


Fig.  22. — Case  I.     Line  of  incision  shown. 


42 


INJURIES    TO    THE    HEAD 


The  thirtieth  day  was  an  important  one  for  the  jiatient.  She  walked 
alone  for  the  first  time  since  the  accident. 

One  year  after  the  accident  the  patient  is  found  to  be  having  occa- 
sional attacks  of  dizziness,  accompanied  by  "  falling-fits."  She  is 
perfectly  sane,  and  talks,  often  very  well  ;  then  there  come  times  of 
difficulty  in  talking,  when  she  can  not  find  the  right  word  to  express 
herself.  Just  after  one  of  these  attacks  of  fainting,  etc.,  talking  is  less 
easy. 

Three  years  after  the  operation  the  following  examination  was  made  : 
The  speech  is  thick,  slow,  and  with  effort.  The  facial  muscles  of  the 
left  side  are  stiff  and  slightly  drawn  ;  they  do  not  move  .so  well  as  on 
the  right  side.  The  left  nasolabial  fold  is  more  accentuated  than  the 
right.  The  left  eyebrow  is  lower  than  the  right.  'J  he  patient  thinks 
that  she  can  hear  better  with  the  right  ear  than  with  the  left.  The 
right  hand  gets  cold  "and  does  not  look  natural."  The  right  fore- 
finger is  often  whiter  than  the  other  fingers  of  the  right  hand.  It  is 
difficult  to  pick  up  needles  or  pins  with  the  fingers  of  the  right  hand. 
I'here  is  no  increase  in  the  wrist-jerks.  The  knee-jerk  is  slightly 
greater  on  the  right  side  than  on  the  left. 

The  patient  says  she  is  enjoying  excellent  health,  eats  and  sleeps 
well,  and  is  out  of  doors  much  of  the  time.      She  is  taking  bromid 

of  potassium  regularly  once  a  day 
in  small  doses.  About  once  a  month 
she  has  a  fainting  or  ' '  weak  spell. ' ' 
These  attacks  are  growing  less  pro- 
nounced and  less  frequent. 

This  case  illustrates  the  important 
fact  that  after  a  severe  head  injury 
with  almost  no  external  visible  sign, 
the  patient  should  be  kept  under 
very  careful  observation  through  the 
hours  immediately  succeeding  the 
accident.  Relative  symptoms  are 
of  far  greater  importance  in  head 
injuries  than  isolated  observations. 
Bleeding  from  the  ear  as  a  symptom 
in  head  injuries  does  not  necessarily 
imply  fracture  of  the  petrous  portion 
of  the  temporal  bone.  Rupture  of 
the  tympanum  may  cause  bleeding 
from  the  ear.  There  was  no  frac- 
ture of  the  skull  detected  after  car*^- 
ful  examination  in  this  case. 

The  interval  of  consciousness  in 
this  case  was  a  somewhat  short  and 
hazy  one.  Immediately  after  the  accident  the  woman  was  dazed,  and 
at  no  time  was  she  herself  mentally.  It  is  to  be  remembered  in  this 
connection  that  the  interval  of  clear  consciousness  may  be  so  masked 
by  the  symptoms  of  concussion  as  to  be  completely  overlooked. 

Case  II. — An   open   depressed  fi'acture   of  the  skull. — Absence  of 


Fig.  23.— Case  11.  Open  depressed  frac- 
ture of  the  skull  :  X,  the  mid-point  be- 
tween glabella  and  inion ;  A,  middle  of 
depressed  bone. 


ILLUSTRATIVE   CASES 


43 


unconsciousness. — Paralysis  of  one-half  of  the  body.  —  Operation. — 
Recovery. 

This  case  illustrates  that  consciousness  may  be  unimpaired  following 
an  injury  to  the  head  severe  enough  to  cause  paralysis. 

A  boy,  nine  years  old,  was  struck  on  the  head  by  a  brick  falling  from 
a  height.  He  was  seen  immediately  after  the  injury  and  found  to  be 
conscious.  He  answered  questions  naturally.  There  was  a  large 
scalp-wound  over  the  parietal  bone  and  a  little  anterior  to  the  parietal 
eminence  to  the  right  of  the  median  line.  The  bone  beneath  the 
scalp-wound  was  fractured  and  depressed  into  the  brain-substance. 
The  left  arm  and  the  left  leg  were  completely  paralyzed  to  motion. 
The  right  pupil  was  dilated  ;  sensation  was  present.  The  right  upper 
eyelid  drooped.  There  was  a  scar  in  the  right  cornea.  Immediately 
after  the  injury  the  temperature  was  96°   F.,  the  pulse  was  74,  the 


Fig.  24. — Case  IIL 


respiration  was  26.  When  examined  one  hour  after  the  accident  the 
pulse  had  fallen  to  6^,  he  had  vomited  once,  and  had  been  somewhat 
nauseated. 

The  operation  of  elevation  of  the  depressed  fragments  of  bone  was 
■done  under  ether.  The  fragments  of  bone  removed  were  about  the 
size  of  a  silver  half-dollar.  There  was  no  fissure  in  the  skull.  The 
dura  mater  was  torn  and  the  brain  slightly  lacerated.  Upon  elevating 
and  removing  the  depressed  bone  hemorrhage  occurred  from  the  ves- 
sels of  the  dura  mater.  The  depressed  bone  was  not  replaced.  The 
dura  was  left  open  and  the  cavity  was  drained  by  a  wick  of  gauze, 
which  was  removed  upon  the  third  day. 

A  few  hours  after  the  operation  the  boy  was  perfectly  conscious  as 
before  the  etherization,  the  pupils  were  normal,  and  motion  had 
returned  in  the  paralyzed  limbs. 


44  FRACTURES    OF    THE    SKULL 

Three  weeks  after  the  opcralion  a  small,  granulating  wound  remained 
and  there  was  a  slight  tendency  to  hernia  cerebri. 

Four  months  following  the  accident  the  hoy's  condition  is  as  fol- 
lows :  The  wound  is  nearly  healed  and  continues  to  discharge  at  times. 
He  walks  naturally.  There  is  no  paralysis  of  arm  or  leg.  No  mental 
symptom  is  present. 

The  interesting  and  unusual  fact  in  this  case  is  that  after  a  blow 
sufficiently  severe  to  cause  a  depressed  fracture  of  the  skull  and 
paralysis  of  one-half  of  the  body  the  ])atient  remained  conscious. 

The  e.xact  location  of  the  injury  to  the  head  and  brain  is  shown  in 
figure  23. 

Case  III. — .-J  bUno  upon  the  head.  —  Uncouscioiisiicss  iiniiicdiafc. — 
S/i}^hf  l>ii/giiig  of  right  eye. — Middle  Dieiiingeal  hemorrhage. — Frae- 
tiire  of  skull.  —  Operation. — Recovery. 

Examination  found  edema  of  the  right  temporal  region.  Uncon- 
sciousness present.  An  inter\al  of  consciousness  was  absent.  Slight 
bulging  of  the  right  eye. 

Operation  in  the  right  temporal  region.  A  skin -flap  was  made  over 
the  fracture  and  edematous  area.  A  fracture  A\'as  detected  running 
from  about  the  middle  of  the  temporal  ridge  an  inch  back  of  the 
coronal  suture  outward  and  forward  across  the  squamous  part  of  the 
temporal  bone  to  a  half-inch  behind  the  pterion. 

The  bone  anteriorly  to  the  fracture  was  depressed.  The  trephine 
was  applied  over  the  depressed  portion  behind  the  coronal  suture. 
Upon  exposing  the  dura  no  pulsation  was  seen.  The  dura  was  dark 
in  color.  A  slight  amount  of  extradural  blood  escaped.  On  follow- 
ing the  fracture  down  to  the  base  of  the  skull  the  dura  was  found 
lacerated,  the  anterior  branch  of  the  middle  meningeal  artery  was 
torn,  and  blood-clot  and  lacerated  brain-tissue  were  present.  The 
anterior  branch  of  the  middle  meningeal  artery  was  tied  and  the 
hemorrhage  ceased.  The  blood-clots  were  removed,  the  exposed  area 
was  cleansed  with  boiled  water,  and  gauze  drainage  introduced.  All 
the  gauze  was  removed  in  four  days.  No  unusual  symptoms  attended, 
convalescence.     Recovery  was  complete  in  three  months  (see  Fig.  24). 

This  case  is  of  interest  because  no  fracture  was  detected  before  the 
operation,  and  it  was  supposed  that  the  bulging  of  the  eye  indicated, 
an  increase  of  intracranial  pressure,  which  proved  to  be  true. 

The  method  of  operating  was  comparatively  simple,  in  that  the 
fracture  was  followed  down  until  the  bleeding  vessel  was  found.  This 
necessitated  the  free  removal  of  bone  below  the  trephine  opening. 

There  was  no  interval  of  consciousness  in  this  case,  and  the  condi- 
tions found  easily  explained  its  absence.  The  man  was  suffering  from 
concussion  and  laceration  of  the  brain  as  well  as  from  intracranial 
pressure,  and  the  interval  of  consciousness  was  obscured  by  the 
jjresence  of  the  concussion.  The  recognition  of  an  interval  of  con- 
sciousness is  of  very  great  importance.  If,  however,  the  interval  of 
consciousness  is  not  present,  as  in  the  case  reported,  intracranial  pres- 
sure from  hemorrhage  can  not  be  said  to  be  absent,  for  concussion 
attendant  upon  the  injury  may  mask  the  interval  of  consciousness 
which  might  have  been  present  had  the  injury  been  less  severe. 


CHAPTER  II 
FRACTURES  OF  THE  BONES  OF  THE  FACE 

FRACTURES  OF  THE  NASAL  BONES 
Anatomy. — The  anatomical  relations  of  the  nasal  bones 
(to  the  perpendicular  plate  of  the  ethmoid,  the  vomer,  the  car- 
tilaginous septum,  the  superior  maxillary  bone,  and  the  frontal 
bone)  make  their  fracture  of  far  greater  importance  than  a  mere 
superficial  disfigurement  of  the  face  would  indicate  (see  Fig. 
25).     The 'site  of  the  fracture  is  usually  near  the  lower  edge 


Vertical  ethmoid  plate. 
/ 
/ 


Frontal  sinus. p 

Nasal  bone. 


Quadrilateral 
cartilage. 


Lower  lateral 
cartilage. 


Sphenoidal 
sinus. 


Vomer. 


Fig.  25. — Median  section  of  nose. 


of  the  bone.  Most  fractures  of  the  nasal  bone  are  open  through 
either  the  skin  or  the  mucous  membrane.  In  nearly  all  nasal 
fractures  the  cartilage  of  the  septum  is  more  or  less  injured. 
The  upper  lateral  cartilages  may  be  torn  from  their  attachments 
to  the  nasal  bones,  simulating  fracture  of  these  bones.  The 
resulting  deformity  of  this  accident  is  well  illustrated  in  figure 
26.  A  high  fracture  of  the  nasal  bones  with  lateral  deformity 
is  shown  in  figure  30:  the  nasal  bone  of  one  side  has  been  im- 

45 


46 


FRACTl'RES  OF  THE  BOXES  OF  THE  FACE 


Fig.  26. — Separation  of  cartilage  from  nasal  Fig.  27. — Fracture  and  lateral  displace- 

bones  (Harrington).  ment  of  each  nasal  bone. 


Fig.  28. — Case  of  fracture  of  nasal  bones. 
Lateral  displacement  (Harrington). 


Fig.  29. — Fracture  and  lateral  displace- 
ment of  each  nasal  bone.  Side  view  of 
figure  27. 


COMPUCATIONS 


47 


pacted  with  the  frontal  bone,  and  the  nasofrontal  articulation 
upon  the  opposite  side  has  been  separated.  Ingures  27  and  29 
show  a  case  in  which,  by  a  direct  blow  squarely  upon  the  nasal 
bones,  the  bones  were  separated  and  one  was  laid  on  one  nasal 
process  of  the  superior  maxillary  bone  and  the  other  was  laid 
upon  the  corresponding  bone.  The  septum  was  intact,  as  is 
•shown  by  the  persistence  of  the  natural  position  of  the  tip  of 
the  nose.     Figures  30  and  31  show  a  syphilitic  nose,  the  septum 


Fig.  30. — Syphilitic  deformity  (Harrington). 


Fig.  31. — Syphilitic  deformity  (same  case  as 
Fig.  30)- 


gone,  and  the  nose  fallen  in.  The  contrast  in  these  two  cases 
is  instructive. 

Symptoms. — Pain,  swelling,  crepitus,  and  deformity  are  usu- 
ally present.  The  subcutaneous  swelling  is  often  so  consider- 
able as  to  obscure  deformity.  Gentle  pressure  is  often  sufficient 
to  detect  crepitus  in  this  fracture,  when  a  firm  grasp  determines 
little  or  nothing. 

Complications. — Through  infection  of  the  internal  or  the 
external  wounds  suppuration  begins,  abscesses  form,  and  nec- 
rosis  of   bone   and   liquefaction   of   cartilage   may   occur.     Em- 


48 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


physema  may  be  noticed  if  the  fracture  is  open  into  the  nasal 
cavity  (see  Fig.  32).  It  will  disappear  after  a  few  days  untreated. 
The  lachrymal  duct  may  be  obstructed  if  the  nasal  process  of 
the  superior  "maxillary  bone  is  involved.  The  nasal  bone  may 
be  forced  up  into  the  floor  of  the  anterior  fossa  of  the  skull,  and 
cerebral  complications  arise  (see  Fig.  15).  If  the  deformity 
following  fracture  of  the  nasal  bones  is  not  corrected,   there  is 


Fig.  32. — Case  of  open  fracture  of  the  nasal  bones.     Emphysema  over  the  forehead  and  the 

upper  part  of  the  face. 


great  likelihood  of  trouble,  either  immediately  or  in  after  years, 
because  of  damage  to  the  nasal  septum. 

The  Nasal  Septum  in  Fracture  of  the  Nose  (see  Figs,  t,;^,  34,  35, 
36,  37). — The  starting  of  the  quadrilateral  cartilage  of  the  sep- 
tum at  some  of  its  bony  attachments  may  be  evident  at  once 
after  the  fracture  of  the  nose  as  a  marked  dislocation,  or  no 
change  may  be  seen  until  long  afterward,  when  a  ridge  due  to 


THE    NASAI.    SEPTUM    IN    FRACTURE    OF    THE    NOSE  49 

inflammatory  thickening  is  found  along  the  previously  loosened 
border.  The  septum  may  be  dislocated  from  its  attachment 
to  the  superior  maxilla,  and  deviate  into  one  nostril  or  the  other 
like  a  curtain.  The  commonest  dislocation  occurs  at  the  junc- 
tion of  the  cartilage  of  the  septum  with  the  vomer  and  the  eth- 
moid. 

Lesions  of  the  septum  due  to  fracture  occur  usually  in  the 
posterior  two-thirds  of  the  cartilaginous  and  in  the  anterior 
balf  of  the  bony  septum.  Fractures  rarely  extend  through  the 
septum  to  the  posterior  nares.  In  fractures  of  the  nasal  bones 
with  little  displacement  the  septum  may  show  no  changes.  Even 
with  considerable  depression  and  comminution  of  the  nasal 
bones,  the  septum  as  a  whole  may  appear  unchanged,  the  lesions 
of  the  septuni  being  confined  to  bowing  or  tearing  at  the  seat 


Fig.  33.  Fig.  34.  Fig.  35.  Fig.  36.  Fig.  37. 

Figs.  33-37. — The  septum  in  fractures  of  the  nose  (Mosher). 

of  fracture.  When  the  nasal  bones  are  much  deviated,  the  free 
■edge  of  the  septum  deviates  with  them.  Fractures  of  the  nasal 
bones  may  occur  alone  or  in  combination  with  fractures  of  the 
septum.  Severe  cases  of  broken  nose  usually  combine  the 
two  conditions.  Fractures  of  the  septum  which  admit  of  classi- 
fication follow  one  of  two  types — horizontal  fractures  or  vertical 
fractures.  The  vertical  fracture  is  much  the  rarer.  It  may 
•occur  anywhere  in  the  course  of  the  cartilaginous  septum,  but 
when  situated  w^ell  back,  is  to  be  distinguished  from  dislocation 
of  the  cartilage.  The  horizontal  fracture  produces  a  gutter- 
like deformity  roughly  parallel  with  the  floor  of  the  nose.  The 
convexity  appears  in  one  naris,  the  concavity  in  the  other. 
Closely  allied  to  these  last  two  fractures  are  the  sigmoid  devia- 
tions, in  which  the  relation  to  fracture  is  unsettled.  They  are 
4 


50  FRACTURES  OF  THE  BONES  OF  THE  FACE 

SO  common  that  they  are  mentioned  for  the  sake  of  complete- 
ness. The  name  describes  them.  They  occur  in  the  same 
two  types  as  the  angular  variety. 

Treatmetit. — The  nasal  cavity  should  be  inspected  by  mirror 
and  light  to  determine  any  lesion  of  the  septum.  Cocain  anes- 
thesia is  necessary  for  this  examination.  If  a  deviation  is  found, 
it  should  be  corrected  along  with  the  correction  of  the  external 
nasal  deformity.  For  this,  primary  anesthesia  will  be  needed, 
as  the  manipulation  is  extremely  painful.  By  external  manip- 
ulation combined  with  elevation  of    the  fragments  and  internal 


Fig.  38. — Fracture  of  nasal  bones.     Elevation  of  depressed  bone  by  instrument   introduced 

into  tfie  nostril. 


pressure  with  Roes  elevator  (see  Fig.  38)  the  deformity  usually 
can  be  overcome.  Any  strong,  narrow,  and  thin  instrument 
will  be  of  service  as  an  elevator.  For  fractures  high  up  with 
displacement,  gauze  packing  carried  well  up  will  be  required 
to  retain  the  elevated  bones.  For  lower  deviations  the  Asch 
tube  will  be  needed.  If  the  nose  is  crushed,  it  will  be  necessary 
to  model  the  nose  over  the  Asch  tube,  one  being  placed  in  each 
nostril  to  preser^'e  the  contour  and  lumen  of  the  nose.  If  there 
is  no  tendency  for  the  deformitv  to  recur,  the  use  of  splints  is 
not  indicated.     Care  must  be  exercised  to  avoid  sudden  pressure 


THE    NASAIv   SEPTUM    IN    FRACTURE    OF    THE    NOSE 


51 


on  the  nose  from  the  rough  use  of  the  pocket  handkerchief. 
In  the  treatment  of  these  cases  special  cleanHness,  perfect  drain- 
age, and  frequent  dressings  are  important.  If  there  is  a  recur- 
rence of  the  external  deformity,  localized  pressure  may  be  ex- 
erted in  various  ways,  all  of  which  are  more  or  less  unsatisfactory. 
The  tin  splint  fixed  to  the  forehead  by  a  circular  plaster 
band  is  of  service.  This  tin  splint,  made  from  ordinary  sheet 
tin,  consists  of  a  forehead  and  a  nasal  portion  moulded  to  the 
forehead  and  to  the  sides  of  the  nose.  The  nasal  portion  may 
be  twisted  or  bent  laterally  to  secure  the  desired  pressure  upon 
the  nose,  the  counterpressure  being  obtained  through  the  fixation 


^^^H^ 

'S^^          ■•Vj*^ 

"flu 

St              .!pB^ 

..  ,M 

^^tm  ...am 

>    ■      - 

m 

■F'"^ 

^^^^H 

Fh 


39. — Cobb's  splint  applied  to  a  case  of  fracture  of  the  nose.     The  head-band  is  so  adapted! 
to  the  shape  of  the  head  that  it  remains  fixed  and  offers  a  point  of  counterpressure. 


secured  by  the  adhesive  plaster  band  to  the  forehead.  Repeated 
adjustments  of  this  splint  are  needed  to  make  it  of  continued 
efhciency;  with  all  care,  however,  the  tin  splint  is  not  generally 
effective. 

The  use  of  adhesive  plaster  strips  (after  Davis)  from  cheek  or 
malar  bone  to  nose  with  small  compresses  is  of  limited  value. 

Cobb's  nasal  splint,  shown  in  figure  39,  is  expensive,  but  is 
very  satisfactory  for  making  direct  pressure  upon  the  nasal 
bones.  The  splint  is  made  of  a  band  of  steel,  fitted  to  the  head 
like  the  hat-band  of  a  hat.  To  this  band  are  attached  an  arm. 
and  a  pad  with  screw  adjustment.  A  strap  over  the  head  and  one 
beneath  the  chin  prevent  downward  and  upward  displacement. 


52  FRACTITRKS    OF    THE    BONKS    OF    THE    FACE 

Coolidge's  splinl  (see  Fig.  40). — This  consists  of  a  tin  pad 
for  the  forehead  with  strap  encircHng  the  forehead  for  the  re- 
tention of  the  pad  in  position.  To  the  lower  border  of  the  pad 
are  soldered  two  wire  arms  upon  which  slide  two  small  felt  pads. 
The  arms  can  be  bent  so  that  counterpressure  may  be  obtained 
upon  the  firm  parts  of  the  face,  while  direct  pressure  with  the 
other  pad  is  brought  to  bear  upon  the  nose.  This  splint  is  in 
expensive  and  is  efficient. 

The  nasal  cavity  should  be  cleansed  at  least  twice  daily  with 
antiseptic  douches.  vSeiler's  tablets,  one  tablet  dissohed  in 
a  quarter  of  a  tumbler  of  warm  water,  used  with  the  Birming- 
ham glass  douche,  make  a  satisfactory  wash.  The  external 
wounds  should  be  dressed  according  to  general  surgical  prin- 
ciples. It  is  well  to  remember  in  this  connection  that  suppurat- 
ing wounds  do  far  better  if  dressed  frequently  than  if  left  to 
accumulate  purulent  discharges. 

After  a  blow  upon  the  nose,  even  if  there  is  no  immediate  de- 
formitv,  the  nose  should  be  examined  to  determine  the  presence 
of  swelling  upon  the  cartilaginous  septum.  Even  a  slight  blow 
upon  the  nose  mav  cause  a  hematoma  of  the  cartilaginous  sep- 
tum (see  Fig.  41).  This  hematoma  is  liable  to  become  infected 
and  to  suppurate.  Considerable  destruction  of  cartilage  may 
follow,  resulting  in  marked  disfigurement  of  the  nose. 

The  involvement  of  the  base  of  the  skull  adds  a  serious  ele- 
ment to  an  ordinary  simple  accident  (see  Figs.  15,  17). 

The  prognosis  as  regards  the  resulting  deformity  must  al- 
ways be  guarded.  Union  usually  takes  place  within  two  weeks 
of  the  accident  and  is  firm  in  one  month.  In  treating  fracture 
of  the  nose  it  is  important  to  be  ever  mindful  of  hematoma  of 
the  septum,  and  of  abscess  of  the  septum  resulting  from  the 
hematoma.  The  external  deformity  that  follows  fracture  does 
not  tend  to  increase,  but  the  internal  deformity  does.  It  is, 
therefore,  of  importance  to  correct  the  internal  deformity  as 
well  as  the  external.  Unless  the  internal  deformity  is  corrected, 
the  nose  may  be  straight  but  obstructed. 


FRACTURES    OF   THE    MAI.AR    BONK 


53 


FRACTURES  OF  THE  MALAR  BONE 

Examination. — Palpation  of  the  malar  bone  is  somewhat 
difficult.  The  best  method  of  doing  it  is  to  stand  behind  the 
sitting  patient   (see  Fig.  42),   and  to  feel  both  malar  bones  at 


Fig.  40. — Coolidge's  nasal  splint :  a,  Forehead  plate  ;  6,  pad  ;  c,  screw  controlling  position  of 

pad  ;  d,  head-strap. 


Fig.  41. — Hematoma  of  the  nasal  septum  (after  Roe). 


the  same  time — the  left  one  with  the  left  hand,  the  right 
one  with  the  right  hand.  The  malar  process  of  the  superior 
maxilla  is  felt  inferiorly  by  pushing  the  skin  of  the  cheek  up- 
ward. The  orbital  part  of  this  process  is  felt  superiorly  at  the 
middle  of  the  inferior  border  of  the  orbit.     Following  the  orbital 


54 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


margin  outward  and  upward,  the  orbital  border  is  palpated  up 
to  the  frontal  process.  Following  the  malar  process  of  the 
superior  maxilla  backward,  the  free  inferior  border  of  the  malar 
is  felt  continuous  backward  with  the  zygomatic  process.  Start- 
ing on  the  frontal  process,  the  posterior  border  of  the  malar 
may  be  palpated  downward  and  backward  to  the  upper  border 
of  the  zygomatic  process  of  the  temporal  bone.  The  inferior 
surface  of  the  malar  may  be  felt  by  placing  the  fingers,  palm 
upward,  in  the  superior  sulcus  of  the  cheek  and  following  back- 
ward until  the  coronoid  process  of  the  lower  jaw  is  felt.  In 
the  case  of  a  fracture  that  is  as  often  unrecognized  as  is  this 


Fig.  42. — Proper  position  from  which  to  palpate  the   malar  bones.     The  fingers   touch  the 
inferior  borders,  the  thumbs  the  posterior  borders,  of  the  malar  bones. 


one  it  is  important  to  be  very  familiar  with  the  details  of  the 
outline  of  the  bone. 

Symptoms. — Fracture  of  the  malar  bone  is  caused  by  a  severe 
blow  upon  the  cheek.  It  is  rather  unusual  to  find  a  fracture 
of  the  body  of  the  bone.  More  often  there  is  a  fracture  of  one 
of  its  processes,  the  line  of  fracture  being  continuous  with  a 
fracture  of  some  adjoining  bone.  The  malar  is  depressed  as  a 
whole,  or  tilted  inward  toward  the  zvgomatic  fossa  because  of  a 
loosening  of  one  or  more  of  its  articulations  or  because  of  a  frac- 
ture or  crushing  of  the  superior  maxilla.  The  deformity  con- 
sists of  a  depression  to  the  outer  side  of  and  below  the  eye.  The 
line  of  fracture  or  separation  can  sometimes  be  palpated. 
Mobility   and    crepitus   are   rarely   obtained.     If   the   depression 


Fig.  43. — Depressed  fracture  of  the  left  malar  bone.    Note  swelling  of  the  left  cheek  and  slight 
hollow  outside  of  left  orbit  (Warren). 


Fig.  44. — Depressed  left  malar  bone.     Same  case  as  figure  43.     Note  depression  behind  and 
below  left  orbit  (Warren). 


55 


56 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


of  the  malar  or  of  an  associated  fracture  of  the  zygomatic  arch 
impinges  upon  the  space  in  which  the  coronoid  process  moves 
in  the  opening  of  the  mouth,  the  motions  of  the  lower  jaw  will 
be  restricted  (see  Fig.  45).  The  limitation  of  motion  of  the 
lower  jaw  may  be  temporary  or  permanent,  depending  upon 
whether  it  is  due  to  hemorrhage  and  swelling  or  bony  pressure. 
The  coronoid  process  of  the  lower  jaw  may  be  fractured  by 
the  same  force  which  fractured  the  zygoma  or  malar.  Localized 
subconjunctival  hemorrhage  may  appear  if  the  orbit  is  involved. 


Ang^le  of 

inferior 

Malar.      maxilla. 


Zyj^oma. 


Articular  pro- 
cess of  infe- 
rior maxilla. 


Coronoid  pro- 
cess of  infe- 
rior maxilla. 


Fig.  45. — Note  relations  of  coronoid  of  inferior  ma.xilla  to  zygomatic  process  and  malar  bones  ; 
the  space  on  either  side  of  the  coronoid  process  is  filled  by  muscle. 


If  the  floor  of  the  orbit  is  fractured  so  that  the  infra-orbital 
nerve  is  implicated,  there  will  appear  prickling  sensations  through- 
out the  area  of  distribution  of  that  nerve — namely,  along  the 
upper  gum,  the  skin  of  the  cheek,  of  the  nose  and  of  the  upper 
lip. 

Treatment. — It  is  sometimes  impossible  completely  to  correct 
the  deformity  except  by  operative  means.  If  any  interference 
with  the  movements  of  the  lower  jaw  persists  after  the  acute 
swelling  disappears, — that  is,  after  two  weeks, — or  if  it  is  very 
evident  at  the  outset  that  the  limitation  of  motion  is  due  to  the 


FRACTURUS    OI^    THU    SUPERIOR    MAXIL1,A  57 

depression  of  bone,  then  operative  interference  is  demanded. 
Before  a  cutting  operation  is  resorted  to  an  anesthetic  should 
be  administered  and  an  attempt  made  by  pressure  with  a  blunt 
instrument  under  the  malar  from  inside  the  cheek  to  raise  the 
depressed  fragment.  If  this  can  not  be  effected,  a  small  incision 
should  be  made  at  the  most  advantageous  point,  avoiding  mak- 
ing the  fracture  an  open  one.  Through  this  incision  access  is 
gained  directly  to  the  bone.  By  means  of  a  narrow  periosteum 
elevator,  retractor,  hook,  or  a  screw  elevator,  the  fragment  can 
be  raised  into  its  normal  position. 

Union  occurs  in  two  weeks.  There  is  no  tendency  to  a  recur- 
rence of  deformity,  therefore  no  retentive  apparatus  is  necessary. 

The  surgeon  is  not  uncommonly  asked  to  remove  the  slight 
depression  attending  a  healed  fracture  of  the  malar  bone.  This 
may  be  most  difficult.  It  should  be  attempted,  however,  as 
in  fresh  injuries,  without  a  cutting  operation,  or  by  an  incision 
within  the  mouth  through  the  mucous  membrane,  or,  if  neces- 
sary, by  an  external  incision. 


FRACTURE  OF  THE  SUPERIOR  MAXILLA 

Fracture  of  the  superior  maxilla  occurs  so  frequently  from 
a  bicycle  injury  that  it  may  properly  be  called  the  bicycle  ac- 
cident. The  blow  causing  this  fracture  is  usually  not  in  the 
direction  to  damage  the  base  of  the  skull,  but  to  tear  the  bones 
of  the  face.  The  nasal  process  of  the  superior  maxilla  may  be 
broken  when  the  nasal  bone  is  fractured.  The  anterior  wall 
of  the  antrum  may  be  broken  by  the  same  blow.  The  alveolar 
process  may  be  broken.  The  damage  to  the  bones  of  the  face, 
and  particularly  to  the  upper  jaw,  is  associated  with  injuries 
to  various  contiguous  bones.  Blows  result  in  many  irregularly 
disposed  fractures. 

The  diagnosis  is  made  by  inspecting  the  mouth,  nose,  and 
cheek.  These  fractures  being  open,  there  is  little  difficulty 
in  detecting  them.  A  very  careful  inspection  should  be  made, 
with  an  anesthetic  if  necessary,  to  determine  the  extent  of  the 
lesions.  Emphysema  and  great  swelling  of  the  face  occur. 
There  may  be  no  wound  of  the  skin.     Whether  the  injury  to 


58  FRACTITRES    OF    THE    BONES    OF    THE    FACE 

the  upper  jaw  is  associated  with  injuiy  to  the  base  of  the  skull 
or  not  can  be  determined  in  the  absence  of  visible  signs  by  the 
subsequent  development  of  cerebral  symptoms.  Necrosis  of 
bits  of  bone  is  rare  after  upper-jaw  fractures,  excepting  fracture 
of  the  alveolar  border.  Hemorrhage  may  be  considerable,  but 
it  is  easily  controlled  by  pressure.  The  infra-orbital  nerve  may 
be  damaged.  The  lachrymal  canal  may  be  temporarily  com- 
pressed or  obliterated. 

Treatment. — If  there  is  no  wound  of  the  skin  and  much 
depression  of  the  jaw,  so  that  the  face  is  knocked  in,  it  will  be 
necessary  to  devise  some  method  of  elevating  the  depressed 
bone  and  of  restoring  the  normal  contour  of  the  face.  To  avoid 
a  visible  scar,  the  mucous  membrane  should  be  incised  on  the 
inner  side  of  the  upper  lip,  and  the  fragments  elevated  by  an 
instrument  introduced  through  the  incision.  As  little  bone  as 
possible  should  be  removed,  so  as  to  leave  sufficient  support  to 
the  soft  parts  of  the  cheek  after  healing.  Only  thus  can  a  falling 
in  of  the  cheek  be  prevented.  If  access  through  the  mouth  is 
unsuccessful,  it  may  be  necessary  to  incise  the  skin  over  the 
fracture.  This,  of  course,  is  to  be  avoided  if  possible.  The 
accidental  wounds  should  be  thoroughly  and  vigorously  swabbed 
with  a  solution  of  corrosive  sublimate  (i :  5000).  The  use  of  tiny 
swabs  of  gauze  held  by  forceps  will  facilitate  this  procedure. 
The  avoidance  of  sepsis  in  these  cases  is  of  paramount  importance. 
If  the  wounds  become  septic,  there  is  great  danger  of  an  exten- 
sion of  the  inflammatory  process  to  the  deeper  parts  or  even 
to  the  meninges  of  the  brain.  Lacerations  of  the  soft  parts — 
lips  and  cheeks — may  have  their  edges  approximated  to  secure 
less  scar  than  if  left  unsutured.  Toose  small  bits  of  bone  should 
be  removed  with  forceps  and  scissors.  Loosened  teeth  should 
be  left  in  good  position  in  their  sockets.  A  mold  of  the  lower 
jaw  should  be  taken  in  composition  or  plaster-of-Paris,  if  pos- 
sible, by  a  competent  dentist,  and  a  rubber  splint  made  from 
this  mold  to  fit  the  teeth  and  alveolar  border  of  the  lower  jaw. 
When  this  splint  is  applied,  its  upper  surface  may  be  brought 
up  against  the  teeth  of  the  upper  jaw  and  held  snugly  in  ap- 
position by  an  external  bandage,  as  in  fracture  of  the  lower 
jaw.     This  splint  will  materially  assist  in  reducing  the  displace- 


TREATMENT  59 

ment  of  the  upper-jaw  fragments.  It  may  be  possible  for  a 
dentist  to  apply  a  splint  directly  to  the  alveolar  margin  and 
teeth  of  the  upper  jaw.  If  this  is  possible,  greater  security  of 
fragments  will  be  obtained  than  by  any  other  method  of  treat- 
ment. The  physician  may  greatly  assist  in  immobilizing  the 
fracture,  until  a  permanent  dressing  is  applied,  by  making  quickly 
a  temporary  splint  of  dental  wax  or  dental  composition,  and 
applying  it  to  the  teeth  and  alveolar  margin  of  the  upper  jaw. 
This  composition  is  softened  and  made  malleable  by  placing 
it  in  hot  water;  it  can  then  be  molded  on  the  jaw,  and  in  two 
or  three  minutes  is  firm  (see  Fracture  of  the  Tower  Jaw). 

After  Care. — Six  weeks  to  two  months  will  be  necessary  to 
insure  firm  vmion  and  freedom  from  complications.  The  swell- 
ing associated  with  the  reparative  process  will  gradually  sub- 
side. Great  care  must  be  exercised  in  the  nursing  of  the  patient 
after  this  injury,  as  the  element  of  shock  is  an  important  one 
to  be  considered.  Strychnin  sulphate  (^^  of  a  grain),  given  two 
or  three  times  daily,  is  indicated  if  there  is  evidence  of  shock 
following  the  accident.  This  should  be  continued  each  day  for 
as  long  a   period   as  shock  is  evident. 

Proper  nourishment  under  these  adverse  conditions  of  ad- 
ministration is  to  be  given  careful  consideration.  Liquids 
alone  are  to  be  used  the  first  week.  These  may  be  given  by  en- 
emata  or  by  the  mouth  with  a  tube  to  the  back  of  the  pharynx 
or  by  a  nasal  tube  if  necessary.  Nasal  feeding  is  simply  and 
easily  carried  out.  A  rubber  tube  three  feet  long  is  needed,  to 
one  end  of  which  is  attached  a  funnel  and  to  the  other  end  a  soft- 
rubber  catheter,  in  size  No.  lo  F.  The  patient  is  half  reclining 
while  the  surgeon  introduces  the  catheter  into  the  nose  until 
it  passes  well  back  and  down  into  the  pharynx.  The  funnel, 
somewhat  elevated  a  foot  or  more  above  the  patient's  head,  is 
kept  filled  with  the  liquid  nourishment  so  that  its  contents  run 
slowly  into  the  esophagus.  A  plug  of  absorbent  cotton,  moistened 
with  a  four  per  cent,  cocain  solution,  and  placed  in  the  nose  for 
a  few  minutes  before  feeding,   facilitates  this  procedure. 

The  nose  and  mouth  should  be  douched  and  swabbed  reg- 
ularly each  day.  This  should  be  done  after  feeding  the  patient, 
and  oftener  if  necessary  in  order  to  avoid  all  odor  from  the  mouth. 


6o 


FRACTURES    OF    THE    BONES   OF    THE    FACE 


Alkalol.  two  teaspoonfuls  to  half  a  cup  of  water,  is  a  satisfactory 
wash  for  this  purpose.  The  profuse  dribbling  of  saliva  which 
attends  this  fracture  demands  drainage  of  the  mouth  by  wicks 
of  gauze  placed  in  the  cheeks  and  gauze  handkerchiefs  for  keeping 
the  surrounding  parts  dry.  \\'iring  the  fragments  of  bone  may 
be  necessary  if  there  is  great  displacement.  Wiring  the  alveolar 
border  to  the  body  of  the  jaw  mav  be  demanded.  vSuture  of 
the  bony  fragments  with  chromicized  catgut  will  often  steady 
them  in  position  until  union  takes  place. 

FRACTURES  OF  THE  INFERIOR  MAXILLA 
With  the  exception  of  the  superior  internal  surface  of  the  artic- 
ular process,   practically  the  whole  of  the  inferior  maxilla  may 
be  palpated.     Fractures  of  the  inferior  maxilla  are  caused  by 
direct  violence.     The   seat   of  the   fracture   will   be   determined 


Fig.  46.— Fracture  of  the  inferior  maxilla 
(interdental  splint)  (X-ray  tracing). 


Fig.  47. — Fracture  of  the  inferior  maxilla 
in  two  places.  Alinement  of  teeth  perfect 
(X-ray  tracing). 


by  the  force  and  direction  of  the  blow,  by  the  location  of  the 
teeth  in  the  jaw  (the  jaw  being  weakest  where  the  teeth  have  been 
lost),  by  the  presence  of  any  foreign  body  between  the  teeth 
(such  as  a  pipe),  and  by  the  presence  or  absence  of  muscular 
relaxation.  Fractures  of  the  base  of  the  skull  through  blows 
on  the  jaw  are  more  likely  to  occur  if  the  mouth  is  open.     Frac- 


FRACTURES    OF    THE)    INFERIOR    MAXII.UA 


6l 


tures  of  the  body  of  the  bone  are  common;  of  the  ramus  behind 
the  molar  teeth,  rather  uncommon ;  of  the  condyloid  and  coronoid 
processes,  very  uncommon.      The  seats  of 
fracture  of  the  inferior  maxilla  are  shown  in 
the  accompanying  illustrations  (see  Figs.  46, 

47,  48,  49)- 

Excepting  those  of  the  condyloid  and 
coronoid  processes,  fractures  of  the  inferior 
maxilla  almost  always  open  into  the  mouth. 
They  occasionally  open  through  both  the 
mucous  membrane  and  the  skin. 

Examination. — Even  when  the  patient 
can  not  open  the  mouth  sufficiently  to 
admit  the    examining   finger,  palpation  of 

the  body  and  ramus  of  the  jaw,  with  one  finger  in  the  cheek  and 
another  finger  upon  the  chin,  will  often  reveal  the  seat  of  fracture. 

Symptoms. — Pain,   crepitus,   and  abnormal  mobility  may  be 


Fig.  48. — Fracture  of 
the  inner  side  of  the  alveo- 
lar process,  from  a  force 
applied  to  teeth. 


Fig.  4.9. — Fracture  of  the  lower  jaw,  showing  loss  of  alinement  of  teeth. 


present.  Immediate  swelling  of  the  gum  appears  at  the  seat 
of  the  fracture.  Teeth  contiguous  to  the  fracture  of  the  body 
of  the  maxilla  will  be  either  displaced  or  loosened.     The  displace- 


62 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


ment  of  the  fragments  in  fracture  of  the  body  and  ramus  will 
be  most  easily  detected  bv  noticing  the  differences  in  level  of 
the  teeth  on  each  side  of  the  fracture  (see  Fig.  49).  The  face 
appears  swollen.  After  a  few  days  the  submaxillary  and  ad- 
joining cervical  lymphatic  glands  become  enlarged.  The  salivary 
secretions  are  increased  in  quantity,  and  because  of  the  disin- 
clination to  painful  swallowing,  the  saliva  dribbles  out  of  the 
mouth.  If  the  fracture  opens  into  the  mouth,  suppuration  often 
appears  and  pus  mingles  with  the  saliva.  Particles  of  decom- 
posing food  between  the  teeth  and  in  the  spaces  outside  the  jaw 
within  the  cheeks  add  to  the  bacterial  pabulum.     The  odor  from 


Fig.  50.— Aluminium  splint  to  be  placed  on  teeth.     For  closed  fracture,  a  continuous  capping 
of  gold  or  aluminium  or  other  metal  cemented  upon  the  teeth. 


this  mass  of  foul  material  is  characteristically  penetrating  and 
offensive.  After  a  few  weeks  necrosis  of  bone  may  occur  at 
the  seat  of  fracture,  with  abscess  formation.  A  discharging 
sinus  pointing  to  the  disease  appears.  These  cervical  abscesses, 
often  difficult  to  manage,  occupy  the  region  of  the  body  of  the 
jaw.  The  submaxillary  and  upper  carotid  triangles  may  be 
filled  bv  a  brawnv  infiltration  associated  with  necrosis  of  a  frac- 
tured jaw.  On  the  other  hand,  with  proper  treatment  and  in 
less  difficult  cases  the  course  of  the  healing  process  is  simple 
and  of  easy  management.  Suppuration  is  prevented.  There  is- 
no  necrosis,  and  the  repair  of  the  fracture  takes  place  unhindered. 


FRACTURE  OF  THE;  BODY  OF  THIi  JAW 


63 


Treatment. — The  primary  object  of  treatment  is  the  pres- 
ervation of  the  natural  alinement  of  the  teeth.  This  object 
is  attained  by  a  complete  reduction  of  the  fragments  of  the 
fractured  bone.  If  a  tooth  interferes  with  the  perfectly  accurate 
closure  of  the  mouth,  and  if  the  adjustment  of  the  fragments 
is  prevented  by  the  position  of  the  tooth,  it  should  be  extracted 
at  once.  Ordinarily,  there  is  but  slight  displacement.  This 
displacement  can  be  corrected  by  digital  pressure  upon  both 
fragments. 

Fzacture  of  the  Body  of  the  Jaw. — The  simple  fracture  of  the 


Fig.  51. — Four-tailed  bandage  for  fractured  jaw. 


body  of  the  jaw  without  much  displacement  may  be  tempor- 
arily treated  by  the  four-tailed  bandage,  which  should  hold 
the  teeth  of  the  lower  jaw  closely  in  apposition  with  the  corre- 
sponding teeth  of  the  unbroken  upper  jaw.  As  soon  as  practic- 
able, a  dental  splint  of  rubber  or  aluminium  should  be  made 
and  applied  by  a  dentist.  This  aluminium  splint  fits  the  crowns 
of  the  teeth  some  distance  upon  each  side  of  the  fracture,  and 
holds  the  fragments  firmly  in  apposition  (see  Fig.  50).  It  also 
permits  of  opening  and  shutting  the  mouth.  The  old-time 
four-tailed  bandage  and  extradental  splint  of  millboard  (see 
Fig.   51)   is  inefficient.     As  a  permanent  dressing  it  should  be 


64 


FRACTURES    OF    THE    BONES    OF    THE    FACE 


discarded.     It   is  useful  onlv  as  a  temporary  support.      In  the 
simple  cases,  in  the  absence  of  a  competent  dentist  to  make  the 


Fig.  52. — Fracture  of  the  lower  jaw.     Wiring  witli  silver  wire. 


Fig.  53- — Hard-rubber  splint,  with  arms  and  posterior  strap. 


aluminium  or  rubber  dental  splint,  a  splint  of  silver  wire  passed 
around  many  teeth  upon  each  side  of  the  seat  of  fracture  is  often 
efficient.     The  method  of  wiring  two  adjoining  teeth,  those  on 


fracture;  of  the  body  of  the  jaw 


6.5 


each  side  the  fracture,  is  unsatisfactory  in  that  the  strain  loosens 
the  teeth  and  displacement  is  easily  effected  (see  Fig.  52). 


Fig.  54. — Hard-rubber  splint,  with  arms  and  bandage  applied.     Similar  to  Fig.  53  (Moriarty). 


A 

^fe- 

'\ 

^V 

sd^-^il 

wL        \ 

^" 

Fig-  55- — Hard-rubber  splint;  wire  arms  and  chin-piece  held  together  by  metal  rods  and  nuts. 


Fracture  of  the  body  toward  the  angle  of  the  jaw,  through  the 
region  of  the  molar  teeth,  is  often  less  easily  held  in  good  position. 
To  the  dental  rubber  splint  the  dentist  should  add  lateral  arms  of 
5 


66 


FRACTURES    OF    THE    BONES    OF    THE    FACE 


Fig.  56. — Same  splint  as  seen  in  figure  55  ;  superior  view. 


Fig.  57.— Front  view  of  splint  (figure  55)  with  mouth  closed  (Moriarty). 


FRACTURES  OF  THE  BODY  OF  THE  JAW 


67 


Fig.  58. — Side  view  of  splint  (figure  55)  ;   arms  and  chin-piece  in  position  (Moriarty). 


Fig- 59- "Splint  similar  to  figure  55.     Mouth  maybe  opened  without  impairing  efficiency  of 

splint  (Moriarty). 


68 


FRACTURES    OF    THE    BONES    OF   THE    FACE 


wire,  held  in  position  by  a  posterior  strap  (see  Fig.  53).  These 
wire  arms  increase  the  efficiency  of  the  dental  splint,  for  a  ban- 
dage is  passed  under  the  chin  between  the  wires  and  thus  steadies 
the  jaw  by  upward  pressure  (see  P^ig.  54).  If  a  still  more  efficient 
method  is  demanded,  the  dentist  uses  an  extradental  chin-piece 
of  metal  (see  Fig.  55),  which  is  adjusted  bv  screws  so  that  firm, 
evenly  graduated  pressure  upon  the  fractured  jaw  is  maintained 
between  the  inside  dental  splint  and  the  outside  chin-piece. 
While  wearing  the  splint  the  mouth  can  be  opened  easily  (see 
Figs.  57,  58,  59). 


Fig-.  60. — Modeling  cups  :  A,  used  for  the  upper  jaw  ;  B,  used  for  the  lower  jaw. 


The  Making  of  the  Dental  Splint. — If  an  impression  is  desired 
of  the  crowns  of  the  teeth  and  the  adjoining  gum,  it  is  best  made 
by  using  the  modeling  composition  manufactured  for  the  use  of 
dentists.  The  necessary  amount  of  the  composition  is  dropped 
into  hot  water;  when  soft,  the  composition  is  put  into  the  metal 
impression-cups  (see  Fig.  60).  The  surface  of  the  composition  is 
warmed  by  holding  it  over  a  flame  or  holding  it  again  in  hot  water ; 
then  the  impression-cup  containing  the  softened  composition  is 
placed  in  the  mouth  and  the  impression  made.  Immediately  upon 
the  removal  of  the  mold  from  the  mouth  the  composition  cools  and 
hardens.      From  this  mold  is  made  the  duplicate  of  the  alveolar 


Fig.  6i.— Plaster  cast  of  fracture  of  the 
jaw. 


Fig.  62. — Plaster  cast  of  lower  jaw  articu- 
lating with  upper  jaw. 


Fig.  63.— Simple  vulcanite  splint,  with  boxes  vulcanized  on  each  side  (Moriarty). 


Fig.  64.— Hard-rubber  splint  in  position,  upper  teeth  resting  upon  it  (Moriarty). 


69 


70  FRACTrRES  OF  THE  BONES  OF  THE  FACE 

border  and  the  teeth  in  plaster-of- Paris  (see  Fig,  6i).  The 
hnes  of  fracture  are  clearly  indicated  upon  the  plaster  cast.  With 
a  fine  saw  the  cast  is  cut  upon  these  lines  and  the  lower  teeth  are 
articulated  with  the  plaster  cast  of  the  upper  jaw,  which  has  been 
made.  Plaster  cream  is  used  to  hold  the  sawed  portions  to- 
gether. In  other  words,  the  I'racture  has  been  reproduced  and 
reduced  in  plaster-of- Paris.  Both  upper  and  lower  casts  are  then 
put  upon  an  articulator  (see  Fig.  62).  A  vulcanite  splint  is  made 
from  this  reconstructed  lower  jaw,  and  when  this  is  applied  to  the 
fractured  jaw  as  an  interdental  splint,  the  deformity  is  corrected 
and  comfortably  prevented  from  recurring  (see  Figs.  63,  64). 


Fig.  65. — Interdental  splint  used  in  fracture  of  the  jaw  when  no  teeth  exist  in  upper  alveolar 

arch  (after  Moriarty). 


Fracture  of  the  Ramus  of  the  Inferior  Maxilla  Just  Behind  the 
Molar  Teeth. — The  displacement  is  difificult  to  correct.  The  frac- 
ture is  usually  oblique  from  before  backward  and  downward,  as 
seen  in  the  tracing  (see  Fig.  47).  The  body  of  the  jaw  drops 
downward  and  backward  and  the  ramus  slides  forward.  No  den- 
tal splint  is  practicable,  because  there  are  no  teeth  on  one  side  of 
the  fracture  to  which  the  splint  could  be  attached.  Etherization 
will  often  be  found  helpful,  and  at  times  necessary,  in  the  reduc- 
tion of  this  deformity.  Reduction  is  accomplished  by  pressure 
backward  upon  the  ramus  with  the  thumb  in  the  mouth  and  a 
simultaneous  lifting  forward  and  upward  of  the  body  of  the  jaw. 


TREATMENT 


71 


Reduction  is  maintained  by  an  outside  pad  and  metal  chin-piece 
and  a  buckle  and  strap  splint.  This  buckle  and  strap  splint  (see 
Fig.  66)  is  of  great  advantage  because  it  is  easily  adjusted,  and 
the  amount  of  pressure  can  be  graduated.  It  is  of  importance  to 
note  here  that  even  after  this  fracture  has  been  reduced  and  is  at 
the  outset  apparently  held  reduced  by  the  bandage,  yet  it  will 
usually  slump  away  a  little  and  at  the  end  of  the  first  twenty-four 
liours  after  setting  the  fracture  the  fragments  will  be  found  to  be 
partially  unreduced.  Upon  a  second  application  of  pressure  by 
tightening  the  bandage  the  fragments  will  come  into  apposition 
with  comparative  ease.  By  careful  and  repeated  adjustments  of 
the  bandage  and  padding,  after  a  week  and  a  half  even  in  the 


Fig.  (A. — Molded  leather  chin-piece  with  buckles  and  straps  for  graduated  pressure  upon 
a  fracture  of  the  inferior  maxilla  (after  Moriarty). 


most  obstinate  cases,  the  jaw  will  be  found  to  be  in  good  position, 
with  the  teeth  articulating. 

Fracture  of  the  Body  of  the  Rmnus  upon  the  Same  or  Opposite 
■Sides  of  the  Inferior  Maxilla. — The  fracture  is  difhcult  to  hold 
fixed.  In  this  case  the  dental  aluminium  or  rubber  splint  will  be 
needed,  together  with  the  outside  pressure  made  by  the  metal 
chin-piece. 

Whichever  method  of  treatment  is  adopted,  the  fracture  at 
first  should  be  inspected  daily  in  order  to  insure  accurate  adjust- 
ment of  apparatus.  The  mouth  and  teeth  should  be  kept  scrup- 
ulously clean.  When  practicable,  the  teeth  should  be  scaled  by  a 
•dentist  before  permanent  apparatus  is  applied.     Brush  and  swab 


72  FRACTURES  OF  THE  BONES  OF  THE  FACE 

^vith  some  mild  antiseptic  wash,  such  as  Listerin,  one  part  in  four 
of  water,  should  be  used  after  taking  nourishment  and  before  bed- 
time and  upon  rising  in  the  morning.  The  liquid  nourishment  of 
the  patient  should  be  given  through  a  glass  tube  at  first.  If  it  is 
unwise  to  open  the  mouth,  a  rubber  catheter  may  be  used  behind 
the  molar  teeth.  The  rubber  catheter  with  a  siphon  attached  is  a 
very  satisfactorv  method  of  feeding.  The  general  health  should 
receive  careful  attention.  A  patient  with  this  fracture  is  apt  to 
become  despondent  and  anxious  about  himself,  particularly  if 
suppuration  exists.  The  repeated  swallowing  of  foul  secretions 
impairs  the  appetite,  causes  indigestion  and  generally  poor  health. 
The  loss  of  variety  in  diet  favors  this  condition.     Out-of-door 


Fig.  67. — If  no  lower  teeth  exist,  the  artificial  teeth  may  be  utilized,  as  seen  above,  as  a 
splint.  Boxes  seen  on  sides  of  plate,  to  which  arms  and  chin-pieces  can  be  attached  (after 
Moriarty). 

exercise,  plenty  of  sleep,  a  mild  tonic,  such  as  ferrated  elixir  cali- 
sayae  and  sulphate  of  strychnin,  and  a  little  wine,  will  all  assist 
in  restoring  and  maintaining  good  health. 

Abscesses  which  appear  should  be  treated  by  incision,  evacua- 
tion of  their  contents,  drainage,  and  antiseptic  dressings.  Bits 
of  necrosed  bone  should  be  removed.  Union  in  fracture  of  the 
jaw  occurs  ordinarily  in  from  three  to  five  weeks.  The  apparatus 
is  to  be  worn  until  the  union  of  the  fracture  is  firm. 

Fracture  of  the  coronoid  and  articular  processes  is  to  be  treated 
by  simple  immobilization  of  the  jaw. 

These  various  methods  of  immobilization  mentioned  may  fail 
in  some  unusual  fractures ;  if  so,  suturing  of  the  fracture  through 
the  bone  with  silver  wire  or  other  material  should  be  undertaken. 


CHAPTER  III 
FRACTURES  OF  THE  VERTEBRAE 

Anatomy. — The  forked  spine  of  the  axis  may  be  felt  beneath 
the  occiput  upon  deep  pressure.  The  spines  of  the  third,  fourth, 
and  fifth  cervical  vertebrae  recede  from  the  surface,  and  can  not 
be  felt  distinctly.  The  spines  of  the  sixth  and  seventh  vertebrae 
project  distinctly,  and  can  be  palpated.  At  the  bottom  of  the 
furrow  in  the  middle  line  of  the  back  are  felt  the  spines  of  the 
dorsal  and  lumbar  vertebrae.  The  spinous  processes  from  the 
seventh  cervical  to  the  third  sacral  are  rather  easily  palpated. 
The  spinal  cord  extends  from  the  lower  edge  of  the  foramen  mag- 
num to  the  lower  border  of  the  body  of  the  first  lumbar  vertebra. 
The  phrenic  nerve  leaves  the  spinal  canal  between  the  third  and 
fourth  cervical  vertebrae.  By  palpation  through  the  mouth  the 
bodies  of  the  vertebrae  may  be  felt  down  to  about  the  upper  border 
of  the  body  of  the  fifth  vertebra.  The  cervical  enlargement  of  the 
spinal  cord  is  more  marked  than  the  lumbar.  It  commences  at 
the  third  cervical  vertebra  and  ends  at  the  second  dorsal  vertebra. 
The  lumbar  enlargement  commences  at  the  level  of  the  ninth 
dorsal  vertebra  and  reaches  to  the  twelfth  dorsal  vertebra.  The 
spinal  cord  is  well  protected  from  injury. 

The  vertebrae  commonly  fractured  are  the  fourth,  fifth,  and 
sixth  cervical,  the  twelfth  dorsal,  and  the  first  lumbar.  The  in- 
jury to  the  vertebrae  is  caused  in  one  of  three  ways:  by  a  direct 
blow,  fracturing  the  arches ;  by  a  fall  upon  either  the  head  or  the 
buttocks,  crushing  the  bodies  of  the  vertebrae ;  or  by  forced  flexion 
or  extension  of  the  spine,  causing  a  dislocation  with  or  without 
fracture  of  the  bodies  and  articular  processes.  More  than  one- 
half  of  the  fractures  of  the  cervical  vertebrae  are  fractures  of  the 
spinous  processes.  More  than  two-thirds  of  the  cases  of  fracture 
of  the  dorsolumbar  vertebrae  are  fractures  of  the  bodies  of  those 
vertebrae.  A  dislocation  without  fracture  may  occur  in  the  cervi- 
cal region ;  it  is  rare  in  other  regions  of  the  spine. 

73 


74 


FRACTURES  OF  THE  VERTEBRAE 


It  is  important  in  localizing  spinal-cord  lesions  to  know  the 
point  at  which  each  nerve  arises  from  the  spinal  cord,  because  the 
point  of  origin  does  not  correspond  with  that  at  which  the  nerve 
emerges  from  the  spinal  canal  (see  Fig.  69).  The  point  of  origin 
is  higher  than  the  point  of  exit.  Many  of  the  nerves  pass  obliquely 
from  the  cord,  lying  still  within  the  vertebral  canal  after  leaving 


Fig.  6S.— The  cord  and  its  membranes  in  relation  to  a  vertebra  (diagram)  :  a,  Extradural 
space  ;  6,  dura  ;  c,  subarachnoid  space  ;  rf,  spinal  cord. 


Fig.  69. — Frontal  section  of 
fourth,  fifth,  and  si.xth  cervical  ver- 
tebrae and  cord,  showingthe  origins 
of  spinal  nerve-roots  (after  Riidin- 
ger). 


IVD. 


VD. 


Fig.  70. — Frontal  section  of  third,  fourth,  and  fifth 
dorsal  vertebrae,  showing  oblique  course  of  nerve  bun- 
dles running  downward  (after  Riidinger). 


the  cord  (see  Fig.  70).  These  nerves  within  the  canal  are  liable 
to  pressure  from  the  vertebral  fracture.  For  example,  a  fracture 
of  the  eleventh  dorsal  vertebra  would  injure  not  only  the  cord 
at  this  level,  but  in  addition  might  injure  the  last  dorsal  and  upper 
lumbar  nerves.  The  lower  the  spinal  nerves  arise,  the  longer  is 
their  intraspinal  course.     The  points  of  origin  of  the  spinal  nerves 


EXAMINATION 


75 


from  the  cord  with  reference  to  the  spines  of  the  vertebrae  are  as 
follows  (see  Fig.  71):  The  eight  cervical  nerves  arise  from  the  cord 
between  the  occiput  and  the  sixth  cervical  spine.  The  upper  six 
thoracic  nerves  arise  from  the  cord  between  the  sixth  cervical 
spine  and  the  fourth  dorsal  spine.  The  lower  six  thoracic  nerves 
arise  from  the  cord  between  the  fourth  and  tenth  dorsal  spines. 
The  five  lumbar  nerves  arise  from  the  cord  opposite  to  the  eleventh 
and  twelfth  dorsal  spines.  The  five  sacral  nerves  arise  from  the 
cord  opposite  to  the  first  lumbar  spine.  No  hard-and-fast  rule 
at  present  is  applicable  to  the  enumeration  of  the  lesions  following 
fractures  and  dislocations  of  definite  vertebrae.  From  the  com- 
bined experience  of  such  clinicians  as  Gowers,  Thorburn,  Kocher, 
Putnam,  Dennis,  Walton,  Bullard,  Thomas,  and  others  the  follow- 
ing table  is  constructed,  and  is  valuable  for  practical  use : 


TABLE  STATING  LESIONS  FOLLOWING  INJURY  TO  DEFINITE 
VERTEBRA. 


Spinal 
Segments. 


Vertebra 
Dislocated. 


Muscles   Involved 

Cervical : 

First,    second, 

third     .    .    .  [Death].  Skull  on  atlas,  atlas  on 

axis. 

Fourth     .    .    .  Diaphragm.  Axis  on  third  cervical. 

Fifth    ....  Biceps,  supinators,  deltoid.  Third  on  fourth. 

Sixth    ....  Pronators,  triceps.  Fourth  on  fifth. 

Seventh   .    .    .  Extensors,  flexors  of  wrist.  Fifth  on  sixth. 
Eighth  and  first 

dorsal  ,         .  Intrinsic  muscles  of  hand.  Sixth  on  seventh. 

Dorsal  : 

Second       to 

twelfth     .    .  Intercostal  and  abdominal 

muscles  (trunk). 


Reflexes  In- 
volved. 


Pupil  is  small 
and  reaction 
sluggish. 


Epigastric,  ab- 
dominal. 


Lumbar  : 

Second 

Cremaster.                                  Eleventh     on     twelfth 
dorsal. 

Cremasteric. 

Third 

Fourth 

Fifth 

L 

Adductors. 

Outward  rotators. 

„   ^                f  .1  •  1     n             Twelfth  on  first  lumbar. 

Extensors  of  thigh,  flexors 

of  knee. 

Gluteal. 
Knee-jerk. 

fSacral  : 

First     . 

Extensors  of  foot.                     First  on  second  lumbar. 

Plantar       and 
ankle  -clo- 

Second 

Calf  muscles. 

nus. 

■Third, 

fourth, 

fifth 

Perineal  muscles. 

76 


FRACTL'RES  OF  THE  VERTEBRA 


Examination  of  an  Injury  to  the  Spine. — Four  questions 
are  to  be  answered:  What  was  the  nature  of  the  accident?  What 
does  palpation  of  the  spine  reveal  as  to  the  nature  of  the  lesion? 
^^'hat  is  the  level  of  the  lesion?     Is  the  lesion  partial  or  complete? 

General  Symptoms  Common  to  Fractures  of  the  Vertebrae. 
— Signs  of  shock  will  be  present.  At  the  seat  of  the  bony  lesion 
will  be  found  pain,  tenderness,  abnormal  mobility  and  sometimes, 
crepitus  and  deformity.     The  deformity  will  ordinarily  be  a  back- 


__§  cervical 
nerves- 


;t 


>—-.^  d 


orstti 
npTves* 


. Xoijjer  D 

dorsal  nerves* 


pn.__5  lumbar  n- 
B...5  sacral  iv 


Fig.  71. — Diagram  of  spinal  origin  of  nerves,  according  to  the  level  of  the  spinous  processes.. 


ward  bending,  or  kyphosis,  of  the  spinal  column  at  the  seat  of 
fracture,  unless  there  exists  a  unilateral  dislocation,  when  the 
deformity  will  be  irregular  in  appearance.  The  chief  symptoms 
depend  upon  the  injury  done  to  the  spinal  cord.  In  general  it 
may  be  stated  that  motor  and  sensory  paralysis,  either  partial  or 
complete,  will  be  found  up  to  the  level  of  the  lesion.  The  reflexes, 
are  ordinarily  below  the  lesion,  wanting  at  first  and  increased  later. 
If  a  complete  lesion  is  present  the  reflexes  will  be  entirely  wanting. 


SYMPTOMS  77 

Retention,  and  later  incontinence,  of  urine  and  feces  will  exist. 
Cystitis  of  the  urinary  bladder  will  develop  at  an  early  date.  Bed- 
sores and  great  sloughing  areas  of  skin  upon  dependent  parts  will 
be  discovered  early.     Priapism  occurs. 

Symptoms  of  Fracture  of  the  Different  Regions  of  the 
Spine,  the  Cord  Being  Involved. — Injuries  to  the  Last  Dorsal 
and  Lumbar  Vertebrce  (see  Figs.  72,  73,  74).— The  spinal  cord  ends 
opposite  the  lower  border  of  the  first  lumbar  vertebra.  Any 
pressure  at  this  point  or  below  will  involve  the  cauda  equina  in 
whole  or  in  part  (see  Figs.  75,  76).     Local  evidences  of  the  bony 


Fig.  72.— Fracture  of  the  twelfth  dorsal  vertebra.     Anesthesia  to  the  height  of  the  anterior 
superior  spinous  processes  in  front.     Second  lumbar  nerve  involved. 

lesions  may  be  present.  The  paralysis  of  the  legs  may  be  partial 
or  complete.  The  anesthesia  of  the  lower  limbs  is  partial  rather 
than  complete  and  up  to  the  level  of  the  bony  lesion.  Retention 
or  incontinence  of  urine  and  feces  exists.  The  paralyzed  muscles 
rapidly  become  wasted.  Constant  pain  and  hyperesthesia  may 
be  present  both  above  and  below  the  lesion.  The  patellar  and 
plantar  reflexes  are  usually  lost. 

The  prognosis  is  not  altogether  unfavorable  to  recovery.  Par- 
tial recovery  is  possible.  Later,  muscular  contractures  wall  exist 
in  the  lower  limbs,  which  impede  walking.  If  at  the  end  of  six 
weeks  evidences  of  beginning  recovery  do  not  appear,  or  if  recovery 


78 


FRACTURES  OF  THE  VERTEBR.K 


© 


Wi^V 


Fig.  73-  Fig.  74. 

Figs.  73,  74. — Fracture  of  the  twelfth  dorsal  vertebra  without  involvement  of  the  first  lum- 
bar nen-e-roots,  the  ilioinguinal,  iliohypogastric,  and  external  cutaneous  nerves  not  being 
involved. 


Fig.  75.  Fig.  76. 

Figs.  75,  76. — Injury  to  the  Cauda  equina,  which  has  involved  the  third  sacral  nerves.     Frac- 
ture of  the  first  lumbar  vertebra  or  the  second  lumbar  vertebra. 


SYMPTOMS 


79 


once  begun  has  ceased,  it  will  be  wise  to  operate  upon  injuries  to 
the  Cauda  equina. 

Injuries  to   the  Dorsal    Vertebrce    (second  to  the  eleventh)   (see 
Fig-    77)- — The  simple  distribution  of  the  spinal  dorsal   nerves 


Fig.  77. — Sixth  dorsal  vertebra  fractured.     Anesthesia  at  the  level  of  two  inches  above  the 
umbilicus.     The  eighth  or  ninth  dorsal  nerve  involved. 


Fig.  78.—  Lesion  of  spine  between  fifth 
and  sixth  cervical  vertebrae.  Note  position 
of  arms,  due  to  paralysis  of  subscapularis. 
Biceps  brachialis  anticus,  supinator  longus 
and  deltoid  muscles  intact.  Elbow  flexed, 
shoulders  abducted  and  rotated  outward 
(after  Thorburn). 


Fig.  79. — Luxation  of  sixth  and  seventh 
cervical  vertebras  ;  typical  attitude ;  center 
for  subscapularis  not  involved.  Contrast 
figures  78  and  79  (after  Kocher). 


below  the  first  makes  the  interpretation  of  injuries  to  this  region 
much  easier  than  similar  injuries  to  the  cervical  or  lumbar  regions. 
The  arms  escape  paralysis.  The  motor  and  sensorv  paralysis 
extends  ordinarily  to  the  height  of  the  bony  lesion.  In  a  few  cases 
in  which  the  nerve-trunks  within  the  canal  are  not  implicated  the 


8o 


FRACTURES   OF   THE   VERTEBR.-E 


level  of  the  paralysis  will  be  lower  than  the  lesion.  The  patellar 
reflexes  are  at  first  generally  lost  in  the  severer  tvpes  of  fracture. 
If  the  patient  recovers,  there  will  be  spastic  paralysis  if  the  injury 
is  above  the  lumbar  enlargement.  If  the  lumbar  enlargement  is 
involved,  there  may  be  great  pain  in  the  legs. 

Injuries  to  the  Cervicodorsal  Region,  Opposite  the  Cervical  En- 
largement of  the  Spinal  Cord. — The  arms  escape  paralvsis,  per- 
haps, at  first,  but  become  involved  after  several  davs.  The 
paralysis  is  often  partial.  Respiration  is  diaphragmatic  only. 
Pain  in  the  arms  is  quite  constant.  If  the  sixth  vertebra  is 
dislocated  upon  the  seventh,  the  intrinsic  muscles  of  the  hand 


Fig.  80. — Lesion  of  spine  between  sixth 
and  seventh  cervical  vertebrae.  Position  in 
case  of  complete  transverse  destruction  of 
the  cord  just  below  nuclei  for  subscapula- 
ris;  areas  of  anesthesia  shown  (after  Thor- 
burn). 


Fig-.  81.— Atlas,  axis,  and  third  cervical 
vertebra  from  the  front.  Case:  man,  thirty- 
eight  years  of  age  ;  fell  from  a  cart.  Frac- 
ture of  odontoid  process.  Slight  hemor- 
rhage into  the  medulla.  Death  after  forty- 
eight  hours  (Cabot). 


will  be  paralyzed.  If  the  fifth  vertebra  is  dislocated  upon  the 
sixth,  there  will  appear  a  characteristic  position  of  the  upper 
extremities  (see  Fig.  78) :  abduction  of  the  arms,  flexion  of  the 
forearms,  with  rotation  outward  of  the  whole  extremity.  If 
the  injury  is  above  the  sixth  cerv^ical  vertebra,  there  will  be 
anesthesia  of  the  entire  limb  excepting  the  shoulder.  The 
attitude  after  lesions  between  the  sixth  and  seventh  cervical 
vertebrae  is  shown  in  figure  79.  The  characteristic  attitude 
in  lesions  between  the  sixth  and  seventh  cervical  vertebrae  is 
also  shown  in  figure   79. 

Injuries  to  the  Midcervical  Region. — A  lesion  of  the  third  cer- 


PROGNOSIS    AND    TREATMENT  8l 

vical  vertebra  will  involve  the  phrenic  nerve.  The  diaphragm 
will  be  paralyzed.     Death  will  occur  within  a  few  hours. 

Injuries  to  the  First  Two  Cervical  Vertebrae  (see  Figs.  8i,  82). — 
If  the  displacement  is  slight,  life  may  be  spared  until  sudden 
displacement  occurs  or  a  secondary  myelitis  causes  death.  Cases 
of  recovery  are  recorded.  Death  usually  occurs  instantly.  Per- 
haps one  person  in  fifty  thus  injured  recovers  (GowersJ. 

Prognosis. — The  prognosis  depends  upon  the  amount  of 
injury  to  the  spinal  cord.  The  prognosis  is  less  grave  than  it 
was  thought  to  be  a  few  years  ago.  There  is  a  probability  of 
saving  a  certain  proportion  of  cases.     In  general,  the  nearer  the 


Fig.  82. — Fracture  of  the  atlas  and  axis.  Man,  seventy-four  years  of  age;  fall;  imme- 
■diatelv  left  arm  paralyzed.  No  loss  of  consciousness,  speech  thick.  Neck  movements  nor- 
mal. Twenty-four  hours  after  the  accident,  suddenly  difficult  breathing  appeared  and  death 
followed  (Brooks). 


fracture  approaches  the  medulla  oblongata  and  the  foramen 
magnum,  the  more  serious  does  the  outlook  become.  Patients 
with  fracture  in  the  dorsal  and  lumbar  regions  die  in  the  course 
of  months  from  cystitis,  pyelitis,  and  exhaustion.  Patients  with 
fractures  in  the  upper  dorsal  and  lower  cervical  regions  die  in  a 
few  days  or  weeks  from  hypostatic  pneumonia.  Patients  with 
fractures  high  up  in  the  cervical  region  die  instantly  or  in  a 
few  hours  from  shock  and  direct  pressure  upon  the  medulla 
oblongata. 

Treatment. — The  object  of  treatment  is  to  relieve  the  cord 
from  pressure   and   to   immobilize   the  fracture.     The  cord  v.ill 


82 


FRACTURES  OF  THE  VERTEBR.-E 


be  uninjured,  slightly  injured,  or  injured  seriously.  If  the 
cord  is  uninjured,  the  bony  parts  may  be  left  untouched  or 
they  may  be  replaced  by  manipulation  or  operation.  If  the 
cord  is  injured,  the  advisability  of  operative  interference  will 
depend  upon  whether  the  lesion  of  the  cord  is  transverse  and 

complete,  or  whether  it  is  partial. 
If  there  are  evidences  of  a  trans 
verse  lesion,  operation  is  unavail- 
ing and  obviously  illogical,  for 
the  cord  can  not  be  repaired.  It 
is  necessary,  therefore,  to  distin- 
guish between  the  signs  of  a 
t>-ansverse  lesion  and  those  of  a 
partial  lesion.  In  a  complete 
transverse  lesion  the  history  of 
the  onset  of  the  symptoms  is  a 
sudden  one,  the  symptoms  ap- 
pear immediatelv  following  the 
fracturing  trauma ;  whereas,  if  a 
partial  injury  is  present,  an  in- 
terval will  have  elapsed  before 
the  symptoms  develop;  the  ap- 
pearance of  symptoms  is  gradual 
rather  than  sudden.  In  a  com- 
plete transverse  lesion  the  motor 
paralysis  is  found  to  be  complete, 
and  the  paralyzed  muscles  are 
flaccid ;  whereas  if  the  lesion  is  a 
partial  one,  the  motor  paralysis 
is  limited,  some  muscles  of  the 
limbs  are  paralyzed,  others  are 
not,  and  there  is  often  noticed 
muscular  spasm  in  the  affected  limbs.  In  a  complete  transverse 
lesion  sensation  is  entirely  gone ;  w"hereas  in  a  partial  lesion  some 
sensation  is  present.  The  knee-jerks  are  variable ;  in  the  complete 
transverse  lesion  they'  are  absent.  In  the  partial  lesion  the  knee- 
jerks  are  apt  to  be  absent  at  first,  and  they  may  return  later.  In 
the  transverse  lesion  the  paralysis  of  the  bladder  and  rectum  is 


Fig.  83. — Fracture  of  the  cervical 
spine;  cord  compressed  by  bone  and 
blood.  Hemorrhage  into  the  cord  at  the 
seat  of  the  lesion  and  below  the  lesion 
(Warren  Museum).     (Drawn  by  Byrnes.) 


TREATMENT 


83 


Fig.  84.— Spine  sawed  in  sagittal  sec- 
tion, showing  fracture  through  the  inter- 
vertebral disc  between  the  sixth  and 
seventh  cervical  vertebrae,  with  disloca- 
tion forward  of  the  upper  fragment.  Par- 
tial crush  of  the  cord  (Thomas). 


Fig.  85. — Spine  sawed  as  before.  Fracture 
of  the  spinous  processes  of  the  seventh  cervi- 
cal and  first  and  second  dorsal  vertebrae. 
Fracture  of  the  bodies  of  the  fifth,  sixth,  and 
seventh  cervical  vertebrae  with  displacement 
backward  of  the  upper  fragment.  Total  crush 
of  the  cord.  The  section  passes  a  little  to  one 
side  of  the  cord,  which  is  seen  in  place,  and 
the  staining  of  the  cord  by  hemorrhage  into  its 
substance  shows  plainly  through  the  mem- 
branes even  in  the  photograph.  The  spinous- 
processes  of  the  second  and  third  dorsal  verte- 
brae were  found  fractured  at  the  operation,  and 
were  removed  (Thomas). 


Fig.  86.  F'g-  87- 

Figs  86  and  Sy.-Spine  sawed  as  before.  Fracture  of  spines  of  fifth  cervical  and  fourth, 
fifth  and  sixth  dorsal  vertebrEe.  Fracture  of  body  of  sixth  dorsal  vertebra.  Displacement 
forward  of  upper  fragment.  Total  crush  of  the  cord,  the  softened  substance  of  which  has 
been  removed  by  the  saw,  leaving  only  the  empty  and  blood-stained  meninges  at  this  point. 
Figure  86  shows  the  spine  as  sawed  ;  figure  87,  the  same  hyperextended,  showing  the  oblitera- 
lion  of  the  narrowing  of  the  spinal  canal  (Thomas). 

84 


TREATMENT 


«5 


complete;  whereas  in  the  partial  lesion  paralysis  of  these  organs  is 
not  always  present.  Priapism,  sweating,  and  involuntary  muscular 
twitchings  are  seen  more  commonly  in  case  of  injury  to  the  spine 
associated  with  complete  lesions  of  the  cord  than  in  cases  with 


Fig.  88.  Fig.  89. 

Figs.  88  and  89. — The  two  lialves  of  the  spine  sawed  in  sagittal  section.  Fracture  of  the 
seventh  cervical  vertebra,  with  dislocation  forward  of  the  upper  fragment.  Fracture  of  the 
arch  of  the  sixth  and  of  the  spine  of  the  seventh  vertebrae.  Total  crush  of  the  cord.  The 
discoloration  of  the  cord  from  blood  shows  plainly  in  the  plate  (Thomas). 


partial  lesions  of  the  cord.  In  partial  lesions  variations  from  the 
definite  types  of  symptoms  are  seen.  The  symptoms  are  more  or 
less  irregular.  In  total  lesions  of  the  cord  operation  can  do  no 
good.  The  cases  of  pressure  from  fragments  of  bone — that  is,  those 
occurring  for  the  most  part  in  the  cervical  region,  in  which  the 


86 


FRACTl'RES    OF    THE    VERTEBR.4i 


laminae  of  the  vertebrae  are  fractured — demand  operation.  All 
other  cases  of  bony  pressure  are  those  due  to  dislocation  of  verte- 
brae which  are  remediable  either  by  operation  or  manipulation. 
In  these  cases  the  prognosis  depends  upon  the  damage  done 
the  cord. 

It  is  the  result  of  experience  that  in  cases  of  injurv  to  the 
spine  severe  enough  to  do  damage  to  the  cord  usually  irreparable 
injury  has  been  done  by  either  a  distinct  crush  of  the  cord  or 
hemorrhage  into  the  cord.  Hemorrhage  into  the  cord  takes 
place  often  extensively  and  some  distance  from  the  seat  of  the 


Fig.  90. — Case:  Man,  fracture  of  spine;  transverse  section  of  spinal  cord  above  the  lesion. 
Hemorrhage  into  posterior  horn  (Taylor).     (Drawn  by  Byrnes.) 


chief  lesion,  so  that  even  if  the  seat  of  the  crush  of  the  cord  were 
reached  by  operation,  damaging  lesions  would  still  remain  un- 
relieved. 

It  is  also  a  result  of  experience  that  removal  by  operation  of 
the  laminae  and  spines  of  the  vertebrae  in  the  suspected  region 
of  fracture  very  rarely — almost  never — reveals  any  remediable 
condition  or  affords  any  evidence  of  the  exact  seat  of  the  lesions 
or  their  extent.  The  reason  for  these  facts  is  that  the  dura  at 
the  seat  of  a  crush  of  the  cord,  whether  partial  or  complete,  re- 
mains intact  and  untorn,  and  that  extradural  hemorrhage  is 
unusual.     The  surgeon,  therefore,  after  removal  of  the  laminae, 


TREATMENT 


87 


is  as  much  in  doubt  as  he  was  before.  Operation,  therefore, 
in  complete  lesions  holds  out  no  hope  of  benefit.  It  is  said  that 
the  chances  of  the  symptoms  being  due  to  pressure  by  extra- 
dural blood-clot  or  bone  justify  operative  interference  in  these 
apparently  hopeless  cases.  This  is  true  in  those  cases  in  which 
the  lesion  of  the  cord  is  partial,  but  never  when  the  lesion  is 
completely  transverse. 

Operative  interference,  then,  may  be  summarized  somewhat 
as  follows: 

In  partial  lesions  operation  may  be  demanded;  in  fracture 
of  the  laminae  and  spines  operation  is  demanded ;  in  all  lesions 


Fig.  91. — Case:  Man,   fracture  of  spine;  transverse  section  of  spinal  cord  below  the  lesion 
(Taylor).     (Drawn  by  Byrnes.) 


of  the  Cauda  equina  operation  is  demanded;  in  almost  all  com- 
plete lesions  operation  is  contraindicated. 

It  is  an  interesting  fact  clinically  and  pathologically  that 
in  cords  compressed  at  a  definite  level  with  destruction  of  the 
cord,  at  the  seat  of  compression  there  is  often  found  a  hemato- 
myelia  (hemorrhage  into  the  substance  of  the  cord)  several 
vertebrae  above  and  below  the  fracture,  thus  showing  how  exten- 
sive is  the  acting  force. 

A  study  of  the  drawings  made  from  actual  sections  of  the 
spinal  cords  of  cases  of  fracture  of  the  spine  will  indicate  the 
different  lesions  already  mentioned. 


88 


FRACTl'RES   OF   THE   VERTEBRAE 


Figure  S3  is  from  a  fracture  of  the  cervical  vertebrae,  show- 
ing destruction  of  the  cord  at  the  seat  of  the  lesion,  with  local- 


Fig.  92. — Case  :  Man,  fracture  of  spine  ;  transverse  section  of  spinal  cord  at  the  seat  of 
lesion  (Taylor).     (Drawn  by  Byrnes.) 


Fig-  93- — Case :  Fracture  of  the  spine  ;  transverse  section  of   spinal  cord  several  segments 
from  the  lesion  ;  hemorrhage  into  the  white  matter  (Taylor).     (Drawn  by  Byrnes.) 

ized  pressure  from  bone  and  blood.  Low  down  is  seen  an  ex- 
tensive extradural  hemorrhage  and  a  hematomyelia  some  dis- 
tance from  the  original  trauma. 


TREATMENT  89 

Figure  90  is  from  a  dislocation  and  fracture  of  the  fifth  upon 
the  sixth  cervical  vertebra.  There  was  complete  paralysis 
below  the  lesion.  Trephining  was  done.  The  patient  lived 
without  improvement  seventeen  days.  This  section  of  the  cord 
is  taken  a  little  above  the  lesion  and  shows  clearly  a  hemato- 
myelia  of  the  right  posterior  cornu. 

Figure  91  is  taken  from  a  section  of  the  cord  of  the  preceding 


Fig.  94. — Partial  fracture  of  twelfth  dorsal  and  fracture  of  first  lumbar  vertebrae.  Fall  of 
twenty  feet  on  nares.  Paraplegia  and  sphincter  paralysis.  Death  nine  months  after  acci- 
dent.    Died  of  phthisis.     Type  of  compression  fracture  (Warren  Museum,  specimen  941). 

case    a   little   below   the   lesion,    showing   complete    destruction 
of  the  gray  matter  of  the  cord;  the  dura  remained  intact. 

Figure  92  is  also  taken  from  a  section  of  the  cord  of  the  pre- 
ceding case,  but  at  the  seat  of  the  lesion,  showing  a  destruc- 
tion of  the  gray  and  white  matter  of  the  cord  anteriorly  next 
to  the  bodies  of  the  vertebrae.  The  dura  remained  intact,  there 
being  to  the  operating  surgeon  no  evidence  posteriorly  of  any 
disturbance  having  occurred  anteriorly. 


90 


FRACTURES  OF  THE  VERTEBRA 


Figure  93  is  a  section  of  the  spinal  cord  of  a  woman  who  fell 
from  a  trapeze  to  the  net,  and  fractured  and  dislocated  the 
sixth  cervical  vertebra.  Operation  was  done.  She  lived  three 
davs.  A  little  distance  (two  segments)  from  the  seat  of  the 
lesion,  where  the  cord  was  crushed  anteriorly,  was  found  a  hemato- 
myelia  of  the  white  matter  posteriorly.     The  dura  was  intact. 

These  specimens,  which  illustrate  the  common  lesions  of  the 


Fig.  95.— Old  fracture  of  twelfth  dorsal  vertebra,  from  fall  of  thirteen  feet ;  canal  nar- 
rowed. Total  paralysis  of  motion  and  sensation  below  injury.  Died  two  years  after  accident 
(Warren  Museum,  specimen  4629). 


spinal  cord  following  fractures  and  dislocations  of  the  vertebrae, 
demonstrate  the  utter  futility  of  operative  interference  in  cases 
of  crush  of  the  cord  with  signs  of  a  complete  transverse  lesion. 
The  Immediate  Rectification  of  the  Deformity  and  Immobiliza- 
tion hy  the  Plaster-of- Parts  Jacket. — With  our  present  knowl- 
edge of  the  pathology  of  these  fractures,  and  excepting  cases 
of  fracture  of  the  vertebral  arch  alone  and  pressure  upon  the  cauda 
equina  and  partial  lesions  of  the  cord,  there  can  be  no  doubt  that 


TREJATMENT  9 1 

the  best  treatment  for  fracture  of  the  vertebrae  is  by  means 
of  expectant  methods.  The  methods  are  as  follows:  Immobiliza- 
tion of  the  part  by  a  plaster-of- Paris  jacket  applied  to  the  trunk, 
if  there  is  no  deformity.  If  there  is  deformity,  correction  of 
it  and  immobilization  of  the  spine  in  the  corrected  position. 
The  correction  of  the  deformity  must  be  immediate  to  avoid 
irremediable  softening  of  the  cord  from  pressure;  and  this  may 
occur  even  within  forty-eight  hours. 

Method  of  Applying  the  Plaster-of- Paris  Jacket. — This  differs 


Fig.  95A. — Fracture  of  the  dorsal  vertebrae  with  great  displacement  of  bodies.    The  patient 
lived  two  months  (Warren  Museum,  specimen  No.  6229). 


in  no  respect  from  the  usual  methods  of  application,  with  the 
exception  that  the  patient  should  be  protected  from  any  unusual 
or  sudden  jar  or  movement.  The  trunk  having  been  properly 
protected  by  a  tightly  fitting  shirt,  the  patient  is  carefully  placed 
prone  in  a  hammock.  The  patient  may  be  placed  upon  two 
kitchen  tables,  which  are  gradually  pulled  apart,  allowing  the 
trunk  to  be  unsupported  between  the  tables  until  the  desired 
extension  is  obtained.  If  the  tables  are  used,  great  care  must 
be  exercised  that  proper  assistants  secure  the  shoulders  and 
hips  of  the  patient  during  the  procedure.     Gentle,  firm  pressure 


92 


FRACTURES  OF  THE  VERTEBRA 


is  made  upon  the  projecting  vertebral  spnies  until  reduction 
is  complete.  The  jacket,  reinforced  posteriorly  by  extra  layers 
of  bandage,  is  then  applied.  Death  may  occur  instantly  during 
this  procedure,  but  if  gentle  measures  are  used,  the  likelihood 
of  such  a  catastrophe  will  be  modified.  An  anesthetic  given 
to  primarv  anesthesia  is  often  of  service.  A  sufl'icient  number 
of  assistants  should  be  at  hand — there  should  be  at  least  four. 
It  is,  of  course,  impossible  to  say  what  cases  w'ill  be  saved  by 


Fig. 


-Fracture  and  subluxation  ;  cervical  vertebrae  united  (J.  Mason  Warren  collec- 
tion, Warren  Museum)  (Walton). 


this  means,  but  it  has  been  proved  to  be  a  life-saving  measure 
in  a  few  cases.  The  patient  will  be  more  comfortable  and  more 
easily  managed  after  such  a  procedure.  The  hopelessness  of  the 
results  of  fractured  spine  justifies  the  surgeon  in  undertaking 
almost  any  risk. 

Cystitis. — Ivife  may  be  prolonged,  if  not  saved,  by  the  proper 
treatment  of  this  distressing  affection,  which  is  always  associated 
wdth  fracture  of  the  spine.     In  a  number  of  these  cases  death  is 


GUNSHOT  FRACTURES  OF  THE  VERTEBRA  93 

due  to  a  pyelitis  and  nephritis  following  a  cystitis.  These  com- 
plications may  be  avoided  for  a  definite  time  if  the  bladder  is 
thoroughly  drained  by  urethral  catheter  or  by  perineal  drainage. 
The  bladder  may  be  kept  aseptic  by  douching  regularly  with 
a  solution  of  boric  acid  or  permanganate  of  potash  and  by  the 
internal  use  of  urotropin.  Great  care  should  be  exercised  in  the 
avoidance  of  bed-sores ;  it  is  easier  to  prevent  than  to  cure  them. 
Summary  of  Treatment. — Fracture  of  the  arches  of  the  vertebrae, 
whether  open  or  closed,  should  be  subjected  to  operation.  Frac- 
ture and  compression  of  the  cauda  equina  after  six  weeks  of 
waiting  for  spontaneous  recovery  should  be  treated  by  opera- 
tion. In  partial  lesions  of  the  cord  operation  may  be  demanded. 
All  other  fractures  showing  a  complete  transverse  lesion  of  the 
cord  should  be  treated  expectantly. 


GUNSHOT  FRACTURES  OF  THE  VERTEBRAE 

These  open  fractures  arrange  themselves  into  three  groups 
for  practical  purposes. 

First  group.  Those  cases  in  which  the  viscera  of  the  thorax 
or  abdomen  are  simultaneously  injured. 

Second  group.  Those  cases  in  which  the  bullet  has  entered 
the  spinal  canal  and  has  injured  the  spinal  cord. 

Third  group.  Those  cases  in  which  the  spines  and  laminae 
or  the  arches  of  the  vertebrae  are  injured. 

Treatment. — In  all  cases  the  external  wound  should  be  care- 
fully cleansed  and  protected  by  an  antiseptic  dressing. 

The  degree  of  shock  should  be  observed.  Any  signs  of  a 
lesion  of  the  cord  should  be  recorded.  Evidence  of  damage 
to  the  viscera  within  the  chest  or  abdomen  should  be  sought 
for. 

In  the  absence  of  great  shock  it  is  wise  for  the  surgeon,  under 
antiseptic  and  aseptic  conditions,  to  lay  open  the  wound,  to 
thoroughly  disinfect  it  and  to  attempt  to  ascertain  the  condi- 
tion of  the  cord  and  vertebrae.  If  the  symptoms  point  im- 
mediatelv  to  a  transverse  lesion  of  the  cord  extensive  operation 
is  contraindicated. 

The  character  of  the  damage  done  bv  the  bullet  to  the  verte- 


94  KRACTl'RES    OF    THE    VERTEBRAE 

brre  and  spinal  cord  can  not  be  wholly  determined  except  by 
operation.  In  operating  there  is  always  the  possibility  of  dimin- 
ishing the  chances  of  infection  through  the  bullet  wound  and 
of  relieving  pressure  upon  the  spinal  cord  from  blood  clot  and 
fragments  of  bone. 

A  crushed  cord  is  not  incompatible  with  life.  Such  a  patient 
may  live  for  several  months  or  even  for  several  years.  Opera- 
tion may  prevent  death  from  sepsis,  even  if  a  crush  of  the  cord 
exists. 


CHAPTER  IV 
FRACTURES  OF  THE  RIBS 

Anatomy. — Palpation  of  most  of  the  ribs  is  comparatively 
easy.  The  upper  seven  ribs  on  each  side  articulate  with  the 
sternum.  The  eighth,  ninth,  and  tenth  ribs  are  connected  by 
the  costal  cartilages  anteriorly,  but  the  eleventh  and  twelfth 
ribs  have  no  anterior  attachment.  These  lowest  ribs  are,  there- 
fore, less  liable  to  fracture.  The  first  two  ribs  are  somewhat 
protected  by  the  clavicle  from  direct  violence,  although  great 
depression  of  the  shoulder  may  bring  the  clavicle  to  bear  directly 
upon  the  first  ribs,  and  this  may  be  a  cause  of  fracture.  The 
ribs  are  so  elastic  in  childhood  that  fracture  then  is  extremely 
rare.     Direct  violence  is  the  common  cause  of  fracture. 

Symptoms. — In  partial  fractures  there  may  be  no  symp- 
toms. Upon  forcible  expiration  (as  in  sneezing,  coughing, 
laughing,  crying,  or  in  breathing  hard)  pain  may  be  felt  at  the 
seat  of  fracture.  So  definite  is  the  pain  that  the  patient  may 
be  able  to  place  his  finger  accurately  upon  the  seat  of  fracture. 

Crepitus  is  often  felt  by  the  patient  when  moving  or  mak- 
ing an  expulsive  effort.  Crepitus  is  elicited  for  the  examiner 
by  firmly  placing  the  palm  of  the  hand  flat  upon  the  chest  at 
the  supposed  seat  of  fracture  when  the  patient  coughs.  If 
crepitus  is  present  at  the  time  of  coughing,  a  slight  crunch  or 
click  will  be  felt  and  sometimes  heard.  The  stethoscope  placed 
near  the  supposed  fracture  will  often  assist  in  detecting  the 
crepitus.  The  ribs  should  be  palpated  systematically,  and  the 
■chest  slightly  compressed  between  the  two  open  hands  antero- 
posteriorly  and  laterally  to  detect  crepitus.  The  natural  in- 
clination of  the  ribs  should  be  borne  in  mind  during  palpation. 
Respiration  will  be  short  and  catchy,  and  accompanied  by  a 
characteristic  grunt. 

The  attitude  and  movements  of  the  patient  are  very  deliberate, 

95 


96 


FRACTl-RES    OF    THE    RIBS 


guarded,  stiiT.  and  in  severe  cases  suggest  the  movements  of  a 
child  with  acute  caries  of  the  dorsal  spine.  There  mav  be  a 
slight  cough. 

Complications  of  Fracture  of  a  Rib. — Injury  to  the  pleura 
and  lung  not  uncommonh-  occurs.  Its  existence  is  manifested 
by  cough,  bloody  expectoration,  and  emphysema.  limphysema 
mav  extend  over  the  whole  chest  and  up  over  the  neck  and 
face  (see  Fig.  97),  and  even  over  most  of  the  body.  Emphy- 
sema unassociated  with  a  wound  of  the  superficial  soft  parts 
is   of   little    importance.     Pneumothorax   may   be    present.      In- 


Fig.  97. — Case:  Emphysema  following  fracture  of  the  ribs  on  the  right  side.     Note  the  puffi- 
ness  of  the  face — the  eyes  almost  closed  (Warren). 


jurv  to  the  heart  and  pericardium  and  hemorrhage  from  an 
intercostal  artery  are  unusual.  A  dry  pleurisy,  disappearing 
rapidlv,  localized  at  the  seat  of  fracture,  is  quite  commonly 
detected  by  the  stethoscope.  The  relations  of  a  rib  to  the  pleura 
and  intercostal  vessels  are  important  in  this  connection  (see 
Fig.   100). 

Treatment. — The  complications  must  be  attended  to  accord- 
ing to  medical  principles.  A  cough  mixture,  if  necessary,  con- 
taining morphin  is  a  great  help  during  the  first  week.  It  is 
■difficult   to  reduce  a  fracture  of  a  rib  and  to  hold  it  reduced. 


TREATMENT 


97 


Fie. 


-Fracture  o£   ribs.      Emphj-sema  general.     Adhesive-plaster  swathe  about    chest. 
Note  closure  of  right  ej-e  and  puffiness  of  face  and  hands  (Monks). 


Fig.  99. — Same  case  as  figure  98.     Emphysema  entirely  disappeared.     Contrast  the  two 
appearances  (Monks). 


98 


FRACTURES    OF    THE    RIBS 


The  (k'l'onnitN-  and  loss  of  function  conse(|ncnl  n])(>n  the  union 
of  a  fractured  rib  in  malposition  are  fortunately  not  very  great. 
However,  the  relief  of  the  patient  upon  the  partial  immobili- 
zation of  the  fracture  is  great.  By  pressure  of  the  hand  the 
ribs  mav  be  steadied  and  the  fragments  brought  into  excellent 
apposition,  and  by  a  pad  held  in  place  by  a  swathe  of  adhesive 
plaster  this  apposition  can  be  maintained.  The  application 
of  an  adhesive-plaster  swathe  is  attended  wilh  much  comfort, 
and  is  easily  accomplished.  The  swathe  should  be  broad  enough 
to  cover  the  chest  six  inches  on  either  side  of  the  fracture  of  the 
rib,  and  long  enough  to  extend  three-fourths  of  the  way  around 


Lung. 


Rib. 


.Artery  and  nerve, 
ritiira. 


Rib. 
Arterj'. 


Fig.  100.  — Horizontal  section  of  chest-wall.  The  relation  of  rib  and  intercostal  vessels  and 
nerve  to  pleura  and  lung  is  shown.  Fracture  of  rib  may  cause  serious  injury  (frozen  section^ 
Professor  T.  Dvvightj. 


the  body.  It  is  applied  as  follows :  One  end  is  fixed  to  the  trunk 
of  the  patient  at  the  spine,  the  patient  standing  erect  with  the 
hands  upon  the  top  of  the  head  (see  Fig.  loi).  The  surgeon, 
taking  the  loose  end  of  the  swathe  and  holding  it  taut,  walks 
around  the  patient,  applying  the  swathe  to  the  patient's  chest 
while  the  patient  standing  turns  as  if  on  a  pivot  toward  the 
surgeon  if  possible  (see  Fig.  102).  It  is  important  to  avoid 
covering  the  constantly  moving  abdomen  by  the  swathe.  A 
swathe  made  of  several  long  strips  of  adhesive  plaster,  each  strip 
being  four  inches  wide,  imbricated  in  the  application,  will  often 
prove  more  comfortable  than  a  single  swathe.  The  comfort  attend- 
ing the  wearing  of  such  a  swathe  speaks  much  for  its  efficacy. 


Fig.  loi. — Fracture  of  the  ribs.  Starting  the  application  of  the  adhesive-plaster  swathe 
to  encircle  the  trunk.  Fixation  of  initial  end  of  the  swathe  at  the  spine.  Notice  that  the 
swathe  is  held  taut  as  it  is  applied. 


Fig.  102. — Fracture  of  the  ribs.     Finishing  the  application  of  the  adhesive-plaster  swathe  to 

the  trunk. 

99 


lOO  FRACTURKS    C)F    THE    RIBS 

(Operative  Trcatmoit.  —  If  the  fracture  is  comminuted  or  if 
there  is  gjeat  displacement  that  is  irreducible  by  ])ressure,  an 
incision  and  elevation  of  the  parts  and  immobilization  by  suture 
are  to  be  considered. 

Aftcr-treatmeni. — The  upright  position  will  give  the  most  com- 
fort. The  swathe  should  be  changed  at  least  once  each  week. 
It  will  require  about  three  weeks  for  the  union  to  become  firm. 
A  cotton  swathe  may  be  torn  during  the  third  and  fourth  weeks 
in  place  of  the  adhesive-plaster  swathe.  At  the  end  of  four 
weeks  all  swathes  may  be  removed.  Massage  to  the  seat  of 
fracture  will,  after  the  first  week,  hasten  healing  and  a  restora- 
tion of  the  parts  to  the  normal  position.  If  there  have  been 
anv  pleural  or  lung  complications,  great  precaution  should  be 
exercised  in  the  after-care.  The  avoidance  of  exposure  to  cold 
and  of  great  bodily  exertion  for  a  period  of  two  months  or  more 
following  recovery  from  the  complication  is  necessary. 

Other  injuries,  such  as  strains  of  the  shoulder  and  back,  are 
likely  to  appear  some  days  after  the  acute  symptoms  of  a  frac- 
ture of  the  rib  have  subsided.  It  is  well  to  examine  the  patient 
with  a  fractured  rib  for  associated  injuries.  These  associated 
sprains  often  cause  considerable  anxiety  to  the  patient  for  fear 
that  more  serious  trouble  than  a  broken  rib  exists.  In  patients 
over  fifty  years  old  "neuralgic  pain"  at  the  seat  of  fracture 
will  sometimes  persist  for  several  weeks  after  the  fracture  is 
firmly  united.  This  may  be  relieved  by  applications  of  moist 
heat  to  the  affected  part  and  by  counterirritation  of  a  more 
vigorous  kind.  The  use  of  tincture  of  iodin  and  blisters  is  often 
a  great  help.  In  the  aged  the  shock  of  the  injury  is  consider- 
able. In  feeble  persons  a  pleurisy  or  pneumonia  may  prove 
fatal. 

Treatment  directed  to  the  removal  of  the  emphysema  is  or- 
dinarily unnecessary.  The  emphysema  usually  disappears  in  a 
week  or  ten  days.  If  the  distention  of  the  subcutaneous  tissues 
is  extremely  painful  and  increases  very  rapidly  it  may  be  wise 
to  make  several  antiseptic  incisions  over  them,  allowing  the 
air  to  escape,  to  relieve  the  tension  of  the  skin. 


CHAPTER  V 

FRACTURES  OF  THE  STERNUM 

It  is  difficult  to  palpate  the  sternum  accurately.  The  epi- 
sternal  notch  is  felt  between  the  two  inner  ends  of  the  clavicles. 
The  junction  between  the  first  and  second  portions  of  the  sternum 
is  distinctly  felt  opposite  the  second  costal  cartilage  as  a  ridge. 
The   different   sites   of  fracture   are  shown  in   figure    103.     The 


Fig.  103. — Sites  of  fracture  of  the  ster- 
num (after  specimens  5149,  978,  5151,  5150, 
9761  977i  Warren  Museum). 


Fig.  104.- Separation  of  manubrium- 
and  gladiolus  ;  displacement  of  lower  por- 
tion forward  :  side  view. 


fracture  that  is  usually  due  to  direct  violence  is  seated  in  the 
upper  part  of  the  second  portion  of  the  sternum,  near  the  junc- 
tion of  the  first  and  second  portions.  The  upper  fragment  is- 
displaced  backward  behind  the  upper  end  of  the  lower  fragment 
(see  Fig.  104).  The  displacement,  the  abnormal  mobility,  and 
possibly  crepitus  after  each  respiratory  act  or  upon  coughing,. 


lo: 


FRACTURES    OF    THE    STERNUM 


the  localized  area  of  pain,  all  increased  by  pressure,  help  to  make 
the  diagnosis  certain. 

The  patient  stands  in  a  characteristic  fashion  with  body  bent 
forward.  It  is  almost  impossible  to  distinguish  a  dislocation 
at  the  junction  of  the  first  and  second  portions  of  the  sternum 
from  a  fracture  within  the  first  portion  of  the  sternum.  Care- 
ful palpation  alone  and  consideration  for  the  age  of  the  patient 
will  enable  one  to  decide.  The  ossification  of  the  sternum  takes 
place  irregularly.  At  the  twenty-fifth  year  all  parts  are  usually 
ossified.  The  lesions  sometimes  associated  with  fracture  of 
the  sternum — viz.,  fracture  of  the  ribs  and  injury  to  the  lungs 


Pig.  105. — Position  in,  and  method  of  reduction  of,  fracture  of  the  sternum.     Notice  positions 
of  hands  of  surgeon  and  assistant. 


and  heart — are  usually  so  severe  that  the  patient  does  not  re- 
cover from  them.  If  no  complicating  lesions  are  present,  the 
outlook   for   recovery   is   favorable. 

Treatment  of  Fracture  of  the  Sternum. — Spontaneous  re- 
duction has  occurred  in  several  instances  upon  coughing  or 
sneezing.  If  the  patient  is  placed  upon  his  back  with  his  head 
•extended  over  the  end  of  the  table  and  the  arms  are  then  raised 
above  the  head  and  rotated  outward  slowly  and  forcibly,  the 
deformity  is  sometimes  reduced.  The  body  of  the  patient, 
meanwhile,  is  steadied  by  an  assistant.  Traction  and  counter- 
traction  are  thus  made  upon  the  two  fragments  (see  Fig.   105). 


TREATMENT    OF    FRACTURE    OF    THE    STERNUM  103 

An  adhesive-plaster  swathe  should  be  placed  about  the  chest 
high  up,  and  held  firmly  in  position  by  straps  across  the  shoulders. 
Union  takes  place  in  from  three  to  four  weeks.  The  fracture 
is  not  solid  for  from  six  to  eight  weeks.  After  resting  on  the 
back  in  bed  for  three  weeks  the  patient  may  be  allowed  to  be 
up  occasionally  with  care  to  avoid  violent  exertion.  For  the 
greatest  precaution  a  Taylor  steel  back-brace,  with  apron  and 
liead-support,  should  be  used  for  two  months  after  the  patient 
is  up  and  about.  This  brace  is  similar  to  that  used  in  high  dorsal 
•caries  of  the  spine. 

Operative  Treatment. — Incision  and  elevation  of  the  depressed 
fragment  have  been  done  successfully,  and  are  to  be  considered 
in  difficult  cases  after  the  shock  of  the  original  injury  has  passed 
away.  Cyanosis  and  dyspnea  may  be  in  part  dependent  upon 
the  displacement  of  the  sternal  fragments.  Relief  from  these 
symptoms  is  often  immediate  upon  the  correction  of  deformity. 


CHAPTER  VI 

FRACTURES  OF  THE  PELVIS 

TnH  pelvic  bones  are  generally  considered  inaccessible  see 
Fig.  io6);  but  whh  a  systematic  anatomical  examination,  espe- 
cially if  assisted  by  digital  examination  by  the  rectum  and 
the  vagina,  practically  all  parts  of  the  pelvic  bones  may  be  pal- 
pated,    ^ilovement  of  the  hip  will  often  determine  the  integrity 


Fig.  io6. — Normal  pelvis.     Note  relations  of  pelvic  ring. 

of  the  acetabulum,  which  is,  of  course,  most  difficult  to  palpate 
even  posteriorly  by  the  rectum.  Fractures  of  the  pelvis  are 
occasioned  by  great  violence.  Fracture  occurs  most  often  in 
falls  from  a  height,  and  is  due  to  the  sudden  pressure  upon  the 
pelvis  through   the  thighs   and   hips    (see   Fig.    io8j   or  through 

104 


EXAMINATION    FOR    FRACTURIiS    OF    THIi    PlilvVIS  105 

the  Spinal  column  upon  the  sacrum  and  sacroiliac  synchon- 
droses. Anteroposterior  pressure  and  lateral  compression,  as 
in  the  car-coupling  accident,  are  common  causes  of  fracture. 
From  a  clinical  standpoint  these  fractures  fall  into  two  groups — 
fractures  of  the  individual  bones  without  injury  to  viscera,  and 
fractures  at  different  points  in  the  pelvic  ring  usually  associated 
with  visceral  lesions. 

Fractures  of  the   sacrum,    the   coccyx,    the   symphysis  pubis^ 
and  the  ischium  are  extremely  rare. 


Fig.  107. — Lateral  view  of  adult  pelvis. 

Examination. — The  examination  should  be  systematically 
made  in  order  to  cover  thoroughly  the  irregular  bones  of  the 
pelvis.  The  ilium  of  each  side  should  be  palpated  to  detect 
a  fracture  of  either  crest.  Then  the  two  ilia  should  be  crowded 
gently  but  firmly  together  in  order  to  determine  crepitus  due  to 
the  presence  of  fracture  elsewhere.  Then  the  pubis  and  ischium 
upon  the  two  sides  are  to  be  palpated  externally  as  far  as  is 
practicable.  Finally  a  careful  rectal  and  vaginal  examination 
should  be   made   of  the   pelvic   bones.     The   patient   should   be 


Io6  FRACTIRES    OF    THE    PELVIS 

cathcterized  to  assist  in  determining  the  presence  of  an  injury 
to  the  urinary  tract. 

Fracture  of  the  Ilium  (see  Fig.  109). — This  fracture  is  not 
unusual.  The  crest  of  the  iHum  is  commonly  broken.  Pain, 
swelling,  crepitus,  and  abnormal  mobility  may  be  present.  Local- 
ized tenderness  at  the  seat  of  fracture  may  be  the  only  sign  pres- 
ent. Crepitus,  absent  at  first,  may  be  elicited  several  days 
after  the  injury.  There  is  comparatively  little  displacement. 
Union  occurs  in  from  three  and  a  half  to  four  weeks.  The  pa- 
tient   ordinarily    requires    but    restraint    in    bed.     The    outlook 


Fig.  108. — Fracture  of  acetabulum  ;   force  transmitted  through  femur  (Warreti  Museum, 

specimen  1053). 


is  for  a  good  recovery  unless  there  is  a  visceral  lesion.  vSlight 
deformity  may  be  noticeable  upon  full  recovery  (see  Fig.   no). 

Fracture  of  the  pubic  portion  of  the  ring  of  the  pelvis  is  the 
commonest  fracture.  It  is  usually  associated  with  other  frac- 
tures or  separations  of  bony  surfaces  of  the  pelvis.  Injury  to 
the  urethra  is  not  uncommon  in  this  fracture  (see  Figs.  1 1 1,  112). 

Treatment. — A  snugly  fitting  swathe  encircling  the  pelvis 
should  be  applied  to  assist  in  immobilizing  the  fracture.  If 
the  fracture  is  of  the  ilium  alone,  the  swathe  should  be  applied 
loosely   enough   to   avoid   displacing   the   fragment   of   the   crest 


TREATMENT  OF  FRACTURES  OF  THE  PELVIS 


107 


Fig.  109. — Fracture  of  crest  of  ilium  (Warren  Museum,  specimen  5938). 


Fig.  no. — Case  :  Fracture  of  the  crest  of  the  right  iUuni  :  A,  Deformity  due  to  inward  displace- 
ment of  fractured  bone  ;  B,  posterior  lateral  view  (Porter). 


io8 


FRACTURES    OF    THE    PELVIS 


inward,  thus  causing  permanent  deformity  (see  Fig.  iio).  The 
patient  should,  in  all  cases,  except  simple  fractures  of  the  crest 
of  the  ilium,  be  placed  upon  a  properly  fitting  Bradford  frame. 
Upon  this  frame,  and  in  no  other  way,  can  the  patient  be  com- 
fortably nursed.  The  bed-pan  can  be  adjusted  with  ease  and 
without  disturbing  the  fracture.  The  bed  can  be  most  readily 
changed  and  the  patient  kept  clean  and  comfortable.  If  it  is 
probable  that  movements  of  the  hip-joints  cause  motion  at  the 
seat  of  the  fracture,  the  thighs  should  be  fixed  so  as  to  immobilize 
these  joints.  The  long  outside  wooden  splint  extending  from 
the  axilla  to  below  the  heel  and  attached  at  its  foot  end  to  a 


New  bone  at 
seat  of  separation. 


Sacro-iliac 
synchondrosis. 


Fracture. 


Fig.  III. — Fracture  of  rami  of  pubes  ;  fracture  and  separation  at  sacro-iliac  synchondrosis  ; 
much  displacement  ;  bony  union  (Warren  Museum). 


slat  at  right  angles  to  the  long  upright — a  T-splint — is  the  simplest 
means  of  securing  this  immobilization.  If  the  patient  is  on  a 
Bradford  frame,  sufficient  immobilization  is  easily  accomplished 
by  encircling  the  thighs  separately  or  together  and  the  frame 
with  a  towel  swathe.  Extension  of  the  limbs  by  weight  and 
pulley  may  be  needed  in  addition  in  certain  cases  to  secure  im- 
mobilization of  the  fracture.  Wiring  or  suture  of  the  fractured 
bones  may  be  entertained  and  practised.  Wiring  is  indicated 
if  comminution  or  displacement  of  fragments  is  great. 

Visceral   Lesions. — Associated    with     fractures    of    the    pelvis 
there  may  be  lesions  of  important  viscera.     These  visceral  lesions 


RUPTURE  OF  THE  URETHRA 


109 


Tender  fractures  of  the  pelvis  of  the  very  greatest  seriousness. 
The  trauma  causing  the  fracture  may  at  the  same  time  occasion 
a  rupture  of  the  kidney.  The  bladder,  urethra,  or  bowel  may 
also  be  ruptured.  The  shock  associated  with  a  fracture  of  the 
pelvis  is  great.  If  there  is  a  visceral  lesion,  the  primary  and 
secondary  shock  will  be  very  great. 

Rupture  of  the  Urethra. — This  is  sometimes  associated  with 
fracture  of  the  pelvis  (see  Fig.  113).  It  may  be  due  to  the  original 
trauma,  as  a  fall  or  blow  on  the  perineum,  or  it  may  be  caused 


Fig.  112.— Fractured  pelvis  :  on  the  right,  fracture  across  pubes  and  ischium ;  on  the  left,  frac- 
ture involving  acetabulum  and  sacrosciatic  notch  (Warren  Museum,  specimen  3857). 


by  bony  fragments  lacerating  the  urethra,  or  by  a  simple  sepa- 
ration of  the  symphysis  pubis.  Pain  at  the  seat  of  the  lesion, 
pain  upon  pressure  in  the  perineum,  retention  of  urine,  urethral 
hemorrhage,  swelling  in  the  perineum,  usually  exist.  Under 
these  circumstances  perineal  section  is  indicated  in  order  to 
drain  the  wounded  area  and  the  bladder.  If  a  catheter  can  be 
passed  to  the  bladder  and  the  local  swelling  does  not  increase, 
permanent  or  interrupted  catheterization  is  indicated.  The 
patient    should,    however,    be   watched   carefully   for   the    signs 


]  lO  FRACTfRKS    OK    TIllv    riCI.VIS 

of  extravasation  <if  r.riiu'.  If  at  any  tinu'  thr  calhcter  can  not 
be  passed,  operation  sliDiild  be  done  at  once,  as  in  the  first  in- 
stance. 

If  the  nrethral  nii)tin'e  is  caused  from  above,  tlic  inferior 
surface  of  the  canal  nia\-  be  intact.  If  so,  the  passage  of  the 
catheter  (if  difficult )  nia\-  be  facilitated  by  depressing  tlie  in- 
strument slightlv,  hugging  the  inferior  wall  of  the  urethra. 


Sacrum.   — 


—  S>nipliy- 
sis  puliis. 


-T ; vH Urethra. 


Fig.  113. — Median  section  of  male  pelvis.  Notice  close  relation  of  bladder  and  urethra  to 
the  symphysis  pubis.  Fracture  of  pubic  bone  may  injure  bladder  or  urethra  (frozen  section 
by  Professor  Thos.  Dwight). 


Rupture  of  the  Urinary  Bladder. — This  may  be  either  extra- 
or  intraperitoneal.  \\'hen  the  bladder  is  empty,  it  is  low  down 
in  the  pelvis  and  can  be  injured  only  by  a  fracture  of  the  pelvis. 
The  rupture  of  the  bladder  due  to  fracture  of  the  pelvis  is  usually 
extraperitoneal  and  it  is  situated  on  its  anterior  surface. 

On  account  of  the  fracture  the  patient  can  not  walk.  Rup- 
ture of  the  bladder  itself  might  occasion  inability  to  walk,  at 
least  any  long  distance.     There  is  great  hypogastric  pain,   fre- 


PROGNOSIS  III 

quent  desire  to  micturate  and  inability  to  pass  urine.  A  few 
drops  of  bloody  fluid  escape  from  the  meatus.  Dullness  may 
be  present  in  the  lower  abdomen  and  loins.  vSoon  after  the 
accident,  if  not  immediately,  there  is  great  prostration.  Evi- 
dences of  shock  are  seen  in  the  pallor  of  the  face,  the  anxious 
expression,  the  feeble  pulse,  the  cold,  clammy  skin,  and  feeble 
voice.  The  abdomen  becomes  distended,  the  temperature  rises, 
and  delirium,  coma,  and  death  follow  with  certainty  unless  op- 
erative interference  has  relieved  the  condition  at  a  very  early 
hour  after  the  accident.  The  patient  dies  from  shock,  hemor- 
rhage, or  septic  peritonitis. 

If  the  patient  is  seen  soon  after  the  accident,  before  unto- 
ward symptoms  have  appeared,  and  has  not  micturated  for 
some  littl'e  time,  he  should  be  catheterized.  An  empty  bladder 
will  be  found  or  a  small  amount  of  bloody  fluid  will  be  with- 
drawn, which  rather  confirms  the  other  evidences  of  ruptured 
bladder.  If  there  is  doubt  as  to  the  rupture  of  the  bladder^ 
the  symptoms  should  be  watched.  The  symptoms  of  rupture 
may  be  masked  or  delayed  by  the  associated  lesions.  The 
urine  may  be  tinged  with  blood  because  of  a  contusion  of  the 
bladder.  The  catheter  may  be  passed  through  the  bladder- 
wall,  and  be  felt  to  enter  the  abdominal  cavity,  evacuating 
bloody  fluid.  All  fluid  having  been  removed  from  the  bladder, 
if  a  measured  amount  of  sterile  water  is  injected  into  it,  and  all 
that  was  injected  does  not  return,  presumption  of  rupture  of 
the  bladder  is  very  great.  Under  such  circumstances  the  dull 
area  in  the  groins  and  lower  abdomen  of  extraperitoneal  rupture 
will  be  increased. 

Exploratory  laparotomy  should  be  done,  and  if  the  extrav- 
asation proves  to  be  extraperitoneal,  drainage  of  this  area  is 
demanded.  Temporary  drainage  of  the  bladder,  either  urethral 
or  through  perineal  section,  will  be  needed  to  permit  healing 
of  the  bladder  wound.  The  bladder  wound  is  usually  inacces- 
sible to  suture  in  these  cases. 

Prognosis. — A  guarded  prognosis  should  always  be  given 
in  any  case  of  fracture  of  the  pelvis.  Fractures  of  the  iliac 
crest  ordinarily  recover  in  a  few  weeks.  In  fractures  complicated 
by  rupture  of  the  bladder  or  bowel  the  prognosis  is  extremely 
grave. 


CHAPTER  VII 

FRACTURES  OF  THE  CLAVICLE 

Anatomy. — The  upper  surface  of  the  clavicle  is  subcutaneous 
throughout  its  whole  length  (see  Fig.  1 16).  The  acromioclavicular 
joint  is  at  its  outer  end.  The  sternoclavicular  joint  is  at  its  inner 
end.  The  clavicle  lies  in  a  muscular  plane  made  up  of  the 
trapezius  and  sternocleidomastoid  muscles  above,  and  the  deltoid, 


Fig.  114. — Upper  surfaces  of  the  right  and  left  clavicles. 

pectoralis  major,  and  subclavius  muscles  below  (see  Fig.  116).  It 
is  important  to  recognize  the  situation  and  the  direction  of  the 
acromioclavicular  joint  in  order  to  discriminate  between  a  frac- 
ture of  the  outer  end  of  the  clavicle  and  one  of  the  acromial 
process.  It  is  likewise  important  intelligently  to  palpate  the 
normal   shoulder,   to  determine   that  the  acromial  process  does 


SYMPTOMS  113 

not  form  the  outer  limit  of  the  shoulder,  but  that  it  is  formed 
by  the  greater  tuberosity  of  the  humerus. 

Symptoms. — The  common  seat  of  fracture  is  in  the  middle 
third  of  the  bone  (see  Figs.  1 17-120  inclusive).  The  shoulder, 
having  lost  the  support  of  the  clavicle,  falls  forward  and  drops 
inward,  consequently  the  outer  fragment  that  moves  with  the 
shoulder  drops  below  the  inner  fragment  and  overlaps  it  in  front. 
The  inner  fragment,  having  attached  to  it  the  sternocleidomastoid 
muscle  and  being  comparatively  free  to  move,  is  drawn  slightly 


Fig.  115. — Under  surfaces  of  the  right  and  left  clavicles. 

Upward.  The  attitude  of  the  patient  is  characteristic  (see  Fig. 
121):  he  stands  with  the  head  inclined  to  the  injured  side, 
thus  relaxing  the  pull  of  the  sternocleidomastoid  muscle  upon 
the  inner  fragment.  The  shoulder  upon  the  side  fractured  is 
depressed;  the  elbow  and  forearm  upon  this  same  side  are  sup- 
ported by  the  well  hand.  This  is  the  attitude  of  greatest  com- 
fort. The  shoulder — i.  e.,  the  space  between  the  base  of  the 
neck  and  the  greater  tuberosity  of  the  humerus — is  shortened 
upon  the  injured  side  (see  Fig.  132).     If  the  fracture  lies  within 


114 


FRACTl'RES    OF    TlIlC    CI, AVICI, E 


the  limit  of  the  coracoclaviciilar  H^anient  or  oiilside  of  it,  there 
will  be  no  appreciable  displacenieiU.  Thv  diagnosis  imder  lliese 
circumstances  Avill  be  dilTicult.  Localized  pain  and  the  dis- 
ability of  the  arm  will  suggest  the  lesion  present. 

I'roctitrc  oj  llic  Cluviclc  i)i  i'liililhooil. — More  than  one-third 
of  all  fractures  of  the  clavicle  occiu'  in  children  under  five  years 
of  age.  A  trivial  injury  is  the  usual  cause  of  the  fracture.  A 
little  child  may  fall  from  a  low  chair  or  out  of  bed  and  fracture 


Trapezius 


Deltoid. 


Pectoralis  major. 


Fig.  ii6. — Muscles  arising  from  and  attached  to  the  clavicle,  showing  the  muscular  plane  in 
which  the  clavicle  lies.     X  points  to  the  coracoid  process. 


the  bone.     The  fracture  is  almost  always  incomplete  or  green- 
stick. 

The  child  cries  upon  moving  the  arm.  Lifting  the  child  by 
placing  the  hands  in  the  armpits  causes  pain.  The  arm  of  the 
injured  side  may  be  used  as  naturally  as  the  other  or  there  may 
be  some  disability,  perhaps  simply  a  disinclination  to  use  the 
arm.  If  the  fracture  is  greenstick,  a  tender  swelling  appears 
at  the  seat  of  the  fracture.  If  the  fracture  is  complete,  an  un- 
evenness  will  be  felt  at  the  seat  of  fracture  according  to  the 
amount    of    displacement.     The    displacement    is    usually    slight 


TREATMENT    IN    ADtJl.TS 


115 


in  childhood.  The  characteristic  attitude  seen  in  adults  (see 
Fig.  121)  is  much  less  marked  in  children,  and  if  the  fracture 
is  greenstick,  there  is  no  tilting  of  the  head  and  depression  of 
the  shoulder.  If  the  child,  as  so  often  occurs,  persistently  holds 
the  head  so  that  a  careful  examination  is  impossible,  then  it  is 
best  to  place  the  child  on  its  back,  and  while  its  legs  and  arms 
are  held  firmly,  the  head  and  shoulder  may  be  gently  and  gradu- 
ally separated.     The  examination  can  then  be  completed. 

Treatment  in  Adults. — The  displacement  should  be  corrected 
and    the    corrected    position    maintained    (see    Figs.    123,     124). 


Fig.  117. — Fracture  at  the  inner  and 
middle  thirds  of  right  clavicle  from  above 
(Warren  Museum,  specimen  1214). 


Fig.  118. — Fracture  toward  middle  of 
clavicle,  a  little  to  the  inside  (common 
site) .  Right  clavicle  from  above  (Warren 
Museum,  specimen  987). 


Fig.  119. — Fracture  at  the  outer  and 
middle  thirds  of  left  clavicle  from  above 
(Warren  Museum,  specimen  987). 


Fig.  120. — Fracture  at  the  outer  end  of 
clavicle.  Left  clavicle  from  above  (War- 
ren Museum,  specimen  7900). 


The  indications  are  to  carry  the  shoulder,  and  with  it  the  outer 
fragment,  upward,  outward,  and  backward. 

The  Recumbent  Treatment. — The  displacement  is  most  satis- 
factorily corrected  by  the  patient  lying  recumbent  upon  a  firm 
mattress.  The  weight  of  the  shoulder  in  this  position  does  not 
impede  reduction,  as  in  the  upright  position,  but  assists  it.  A 
firm  and  small  pillow  should  be  placed  between  the  shoulders. 
The  shoulders  fall  backward  of  their  own  weight  over  the  pillow 
carrying  the  outer  fragment  backward  at  the  same  time.  Pad- 
ding of  the  fragments  of  the  clavicle,  the  application  of  pres- 
sure to  the  elbow,  may  be  more  satisfactorily  accomplished  irt 
the  recumbent  than  in  the  upright  position.  Union  ordinarily 
occurs   within   three   weeks.     At   the   time   of  union   or   shortly- 


Fig.  121. — Case  :  Comminuted  fracture  of  the  left  clavicle.    Attitude  characteristic  ;  deformity 
visible;  wired  (Mixter). 


Fig.  122. — A  fracture  of  the  clavicle  at  A,  the  usual  situation,  would  result  in  consider- 
able displacement  of  the  inner  fragment.  A  fracture  situated  within  x  y  is  usually  little  dis- 
placed :  X,  Conoid  ligament ;  y,  trapezoid  ligament ;  z,  coraco-acromial  ligament ;  c,  acromion  ; 
lb,  coracoid  process  ;  e,  scapula  ;  d,  head  of  humerus ;  g,  long  tendon  of  the  biceps  (Aitken). 

Il6 


Fig.  123. — Fracture  of  the  clavicle.  Method  of  correction  of  falling  inward  and  downward 
of  shoulder,  in  overriding  of  fragments  previous  to  the  application  of  the  modified  Sayre 
dressing. 


Fig.  124. — Fracture  of  the  clavicle.    Same  as  figure  123.    Posterior  view,  showing  extreme 

backward  position  of  shoulders. 

117 


Fig.  125. — Fracture  of  the  left  clavicle.  Mod- 
ified Sayre  dressing.  Towel  circular  of  upper  arm 
held  by  adhesive  plaster.  Adhesive-plaster  strap 
ready. 


Fig.  126.— Fracture  of  the  left  clavi- 
cle. First  adhesive-plaster  strap  ap- 
plied. Shoulder  carried  backward. 
Fixed  point  established  above  middle 
of  humerus. 


Fig.  127. — Fracture  of  the  left  clavi- 
cle. First  adhesive-plaster  strap  applied. 
Second  adhesive-plaster  strap  being  ap- 
plied. Hole  in  plaster  for  olecranon  visi- 
ble. Note  pad  for  wrist  and  folded  towel 
protecting  skin  of  arm  and  chest. 


Fig.  128. — Fracture  of  the  left  clavicle. 
First  and  second  adhesive-plaster  straps 
applied.  Pad  in  left  hand.  Shoulder 
pulled  backward  and  elevated. 


118 


the;    MODIFIEL)    SAYRK    DRESSING 


119 


after  the  patient  may  be  allowed  up  with  a  simple  retentive 
dressing,  a  sling,  and  a  swathe.  The  bed  treatment  is  hard  to 
enforce  because  the  fracture  is  the  cause  of  so  little  real  per- 
manent disability.  If  there  is  much  displacement  and  de- 
formity can  not  be  corrected  and  held  properly,  the  bed  treat- 
ment is  indicated.  In  the  simultaneous  fracture  of  both  clavicles 
the  recumbent  bed  treatment  is  the  best  (see  Operative  Treat- 
ment of  Fracture  of  the  Clavicle). 


Fig.  129. — Fracture  of  the  right  clavicle. 
Modified  Sayre  dressing.  Posterior  view. 
Shoulder  elevated  and  pulled  backward. 
Folded  towel  seen  in  axilla  for  protection 
to  skin. 


Fig.  130. — Fracture  of  the  clavicle.  Meth- 
od of  application  of  a  Velpeau  bandage.  Note 
the  order  and  direction  of  the  turns  i,  2,  3, 
4,  and  5.  Note  position  of  the  forearm  and 
arm  of  the  uninjured  side. 


The  Modified  Sayre  Dressing. — The  shoulder  and  arm  are 
unwieldy  in  adults.  It  is,  therefore,  necessary  in  treating  a 
fracture  of  the  clavicle  by  an  ambulatory  method  to  secure  a 
very  firm  hold  upon  the  shoulder  in  order  to  maintain  the  cla- 
vicular fragments  in  a  good  position. 

The  modified  Sayre  adhesive-plaster  dressing  is  the  best. 
It  is  applied  as  follows:  Provide  three  strips  of  adhesive  plaster, 
four  inches  wide,   and  long  enough  to  extend  once  and  a  half 


I20 


FRACTURES    OF    THE    CLAVICLE 


around  the  body.  The  skin  surfaces  that  are  to  come  in  contact — 
namely,  the  axilla  and  chest  and  forearm — are  separated  by 
compress  cloth  and  powder.  A  dressing  towel,  folded  like  a 
cravat,  is  snilglv  pinned  high  up  about  the  upper  arm  (see  Fig. 
125).  This  towel  may  be  held  neatly  by  a  strip  of  adhesive 
plaster.  One  end  of  the  first  adhesive  strap  is  fastened  loosely 
about   the   towel-protected   arm   with   a   safety-pin.      \\Tiile   an 


Fig.  131. — Fracture  of  the  clavicle  and  subluxation  of  the  acromioclavicular  joint.  Notice 
elevation  of  shoulder  by  pressure  on  the  flexed  elbow  and  counterpressure  on  the  clavicle  by 
a  bandage  and  a  pad  (X)  placed  internal  to  the  acromioclavicular  joint. 


assistant  holds  the  shoulder  well  back  the  arm  is  carried  back- 
ward, and  held  by  the  fastening  of  the  first  adhesive  strap  about 
the  body  (see  Fig.  126).  This  affords  a  fixed  point  at  the  middle 
of  the  upper  arm.  The  second  strap,  with  a  hole  in  it  to  receive 
the  point  of  the  elbow,  is  started  upon  the  posterior  surface 
of  the  injured  shoulder  (see  Fig.  127)  and  carried  under  the 
elbow  of  the  injured  side  and  over  the  well  shoulder  (see  Fig. 


TREATMENT    IN    CHILDREN 


121 


128).  The  forearm  is  flexed,  and  rests  upon  the  chest.  In 
applying  this  second  strap  the  shoulder  is  raised  and  the  elbow 
is  carried  forward,  thus  forcing  the  shoulder  slightly  upward 
and  backward  of  the  fixed  point  used  as  a  fulcrum  (see  Fig.  129). 
A  third  strap  may  be  placed  around  the  trunk  and  arm  to  steady 
all  in  good  position.  Over  this  dressing  may  be  put  a  Velpeau 
bandage  for  the  comfort  of  the  support  which  it  affords  (see 
Fig.    130).     The  adhesive  plaster  may  be  covered  with  bits  of 


Fig.  132. — Fracture  of  the  right  clavicle.     Shortening  of  the  shoulder. 


gauze  bandage,  in  part  to  protect  the  skin  from  undue  chafing, 
sufficient  plaster  surface  remaining  uncovered  to  prevent  the 
straps  from  slipping.  Occasionally,  pads  (see  Fig.  131)  upon 
the  clavicle  may  be  used  to  correct  the  deformity,  but  the  bone 
is  so  subcutaneous  that  the  skin  can  not  bear  great  pressure 
without  damage.  If  pads  are  used,  they  must  receive  frequent 
inspection. 

Treatment    in    Children. — The    skin    of   the    child    must   be 
protected  by  powder  and  careful  drying  before  the  arm  is  done 


122 


FRACTURES    OF    Till'    CI.A\'ICI,E 


lip.  If  il  is  a  grcenslick  fracture  and  llicre  is  sli,£^ht  deformity, 
this  defonuitv  should  be  corrected  by  pressure  with  the  thumbs. 
An  anesthetic  should  be  used.  After  the  deformity  is  corrected 
and  in  cases  without  deformity  it  is  necessary  simply  to  restrain 
the  naovements  of  the  arm  for  two  weeks.  This  is  best  accom- 
plished by  a  cotton  swathe  about  the  body  and  upper  arm, 
held  bv  straps  over  the  shoulders  and  by  a  cravat  sling.  In 
warm  weather  and  also  in  cool  weather,  for  that  matter,  the 
arm  is  to  be  inspected  frequently,  as  often  as  every  third  day, 
when  all  the  dressings  are  removed,  the  parts  bathed  with  soap 
and  warm  water,   powdered,   and  the  simple  retentive  dressing 


Fig.  133. —  Fracture  of  right  clavicle  showing  amount  of  callus  present  when  union  was  com- 
pleted.    The  deformity  from  this  callus  entirely  disappeared  after  several  weeks. 


reapplied.  With  this  care  only  can  chafing  be  avoided.  If 
it  is  a  complete  fracture,  the  modified  Sayre  adhesive-plaster 
dressing  should  be  used  as  in  adults.  The  skin  is  to  be  carefully 
protected,  and  the  dressing  most  assiduously  watched.  It 
requires  but  forty-eight  hours  for  great  chafing  to  occur  with 
the  resulting  discomfort  and  the  slow  healing  which  often  re- 
sults. If  union  is  firm  after  two  weeks  or  two  weeks  and  a  half, 
the  plaster  dressing  should  be  removed  and  the  shoulder  put 
up  in  a  simple  retentive  swathe  and  sling,  at  first,  inside  the 
clothes;  after  three  weeks,  outside  the  clothes.  In  very  active 
children  the  sling  should  not  be  removed  until  four  weeks  have 


OPERATIVE   TRIiATMKNT  I  23 

elapsed.  Massage  should  be  given  to  the  forearm,  elbow,  and 
shoulder  after  the  first  week,  together  with  passive  motion  of 
the  elbow.  In  both  children  and  adults  the  adhesive-plaster 
dressing  should  be  reapplied  at  least  once  every  ten  or  twelve 
days.  If  the  dressing  chafes  or  slips,  it  may  need  more  frequent 
renewal. 

Prognosis. — Useful  arms  and  shoulders  usually  result  after 
fracture  of  the  clavicle.  Almost  all  complete  fractures  of  the 
clavicle  with  displacement  of  fragments,  after  repair  has  taken 
place,  show  unmistakable  evidences  of  deformity  at  the  seat  of 
fracture,  of  shortening  of  the  width  of  the  shoulders,  and  in 
many  instances  in  children  of  a  slight  lateral  deformity  of  the 
spinal  column  (see  Fig.  132).  Fractures  within  the  coraco- 
clavicular  ligament  having  little  displacement  of  fragments 
show  no  resulting  deformity.  Very  great  deformity  does  not 
preclude  a  useful  arm.  An  ununited  fracture  of  the  clavicle 
is  unusual;  it  may  exist  and  cause  no  especial  inconvenience; 
it  may  be  unknown  to  the  patient.  An  ununited  fracture  of 
the  clavicle  with  considerable  callus-formation  may  simulate 
malignant  disease  of  the  bone.  Laboring  men  are  rarely  kept 
from  their  work  more  than  two  months.  Fractures  of  the  clavicle 
in  young  children,  if  carefully  treated,  should  unite  with  prac- 
tically no  deformity  or  disability.  Greenstick  or  incomplete 
fractures  may  show  a  general  bowing  of  the  whole  bone,  which 
it  has  been  impossible  to  correct. 

Operative  Treatment. — In  recent  fractures :  If  there  is  great 
displacement  which  can  not  be  held  reduced,  if  sharp  fragments 
threaten  vessels  or  nerves,  if  there  is  pressure  upon  either  nerves 
or  blood-vessels,  if  the  fracture  is  a  comminuted  one,  and  if  the 
bone  is  fractured  in  two  or  more  places  (multiple  fractures),  it 
is  wise  to  consider  operative  measures.  The  fragments  can  be 
exposed,  replaced,  and  held  in  position  by  suturing.  Good 
results  follow  this  treatment.  After  operation  for  fracture  of 
the  clavicle  a  simple  retentive  dressing  of  a  swathe  and  cravat 
sling  will  be  needed.     It  should  be  worn  for  at  least  three  weeks. 

In  Ununited  Fractures. — If  the  cause  of  delayed  union  of  the 
fracture  is  a  misplaced  bony  fragment,  an  interposed  strip  of 
fascia  or  periosteum,  or  an  interposed  subclavius  muscle,  opera- 


124  FRACTURES    OF    THE    CLAVICLE 

tive  interference  may  be  undertaken  with  a  reasonable  expec- 
tation of  securing  a  good  result.  If,  on  the  other  hand,  nonunion 
has  existed  for  a  long  period  (a  year  or  more),  it  is  highly  probable 
that  the  ends  of  the  fragments  will  be  so  attenuated  that  re- 
freshing these  ends  for  suture  would  shorten  the  fragments  to 
such  an  extent  that  suture  would  be  impracticable. 


CHAPTER  VIII 

FRACTURES  OF  THE  SCAPULA 

The;  spine  and  acromial  process,  the  coracoid  process,  and 
the  vertebral  and  axillary  borders  of  the  scapula  can  be  palpated 
with  comparative  accuracy.  Fracture  of  the  scapula  is  of  rather 
unusual  occurrence,  and  always  follows  great  violence  (see  Figs. 

134,   135,   136)- 

Fracture,  of  the  body  of  the  scapula  is  transverse  between 


Fig.  134. — Normal  scapula.     Axillarj-  view. 

the   axillary  and  vertebral  borders  or  comminuted   in  various 
directions  (see  Figs.   137,   138). 

Crepitus,  abnormal  mobility,  local  swelling,  and  tenderness 
are  present.  Pain  is  felt  upon  attempting  to  abduct  the  arm. 
It  may  be  impossible  to  raise  the  arm  to  the  head. 

125 


Fig-  135- — Normal  scapula.     \'entral  view. 


Fig.  136. — Normal  scapula.     Dorsal  view. 
126 


fracture;  of  the  neck  of  the  scapula  127 

Fracture  of  the  Acromial  Process  of  the  Scapula. — The 
epiphysis  of  the  acromion  unites  with  the  scapula  about  the 
twentieth  year.  If  there  is  a  fracture  present,  and  not  a  sepa- 
ration of  the  epiphysis,  which  sometimes  occurs,  the  line  of 
fracture  is  ordinarily  outside  the  acromioclavicular  joint.  A 
fracture  may  occur  through  the  acromion  nearer  to  the  spine 
of  the  scapula. 


Fig.  137. — Fracture  of   the  bodj'  of  the  scapula.      Bony  union  with  moderate   displacement 
(Warren  Museum,  specimen  8111). 


Localized  pain,  swelling,  and  tenderness,  and  a  flattening  of 
the  shoulder  are  present.  Crepitus  may  at  times  be  felt.  If 
the  fracture  is  inside  the  acromioclavicular  joint,  the  flattening 
of  the  shoulder  will  be  considerable.  The  head  of  the  humerus 
is  felt  in  the  glenoid  cavity,  thus  ruling  out  a  dislocation. 

Fracture  of  the  neck  of  the  scapula  is  most  unusual.  If 
present,  it  may  be  mistaken  for  a  dislocation  of  the  humeral 
head. 


125  KRACTIKICS    ( )F    THH    SCAPULA 

The  acromial  process  is  prominent.  The  upper  arm  is  length- 
ened. On  lifting  the  arm  forcibly  ni)\vard  with  the  elbow  Hexed, 
the  deformity  is  corrected,  and  crepitus  is  delected.  The  de- 
formity recurs  if  this  upward  ])ressure  is  removed.  The  reap- 
pearance of  the  deformity  and  the  crepitus  serve  to  distinguish 
this  injury   from  a    dislocated  shoulder.      In  a  thin  person  pal- 


Fig.  13S. — Multiple  fractures  of  scapula.     Railroad  accident.     Man,  forty-three  years  of  age. 
Lived  one  day  (Warren  Museum,  specimen  6028). 


pation  of  the  edges  of  the  glenoid  cavity  itself  will  prove  rather 
satisfactory;  the  crepitus  and  abnormal  mobility  can  thus  be 
more  accurately  located. 

Treatment  in  General. — Immobilization  of  the  whole  upper 
extremity,  except  the  forearm  and  hand,  is  necessary.  Localized 
pressure  may  assist  in  retaining  fragments  in  place. 


TREATMENT   OF    FRACTURES    OE    THE    SCAPULA  1 29 

If  there  is  fracture  of  the  body  of  the  scapula,  the  forearm 
should  be  flexed  to  a  right  angle  and  held  in  a  sling.  The  skin- 
surfaces  coming  in  contact  should  be  protected  by  powder  and 
compress  cloth.  A  swathe  of  cotton  cloth  should  be  fastened 
about  the  upper  arm  and  trunk.  If  the  cloth  swathe  is  not 
sufificient  to  hold  the  scapula  steady,  a  swathe  of  adhesive  plaster 
should  be  used,  broad  enough  to  extend  from  the  acromion  to 
the  elbow. 

Fracture  of  the  Acromial  Process:  The  skin-surfaces  must 
first  be  protected  from  chafing.  The  forearm  being  flexed,  pres- 
sure upward  should  be  made  upon  the  elbow,  so  as  to  lift  the 
arm  and  relax  the  pull  on  the  small  acromial  fragment.  At  the 
same  time  counterpressure  is  made  upon  the  inner  fragment  and 
incidentally  upon  the  inner  shoulder  (see  Fig.  131).  This  pres- 
sure and  counterpressure  will  hold  the  part  reduced.  The  ban- 
dage must  be  inspected  frequently  each  day,  in  order  to  detect 
and  to  relieve  too  great  pressure  upon  the  elbow  and  bony  parts 
of  the  shoulder. 

Union  will  take  place  in  from  three  to  four  weeks.  It  is  ex- 
tremely difficult  to  maintain  the  reduction  of  the  fragment  of 
the  acromion  by  any  apparatus.  The  one  previously  suggested 
meets  the  indications  better  than  any  other.  Massage  will 
materially  assist  in  hastening  the  absorption  of  blood  and  will 
relieve  pain.  No  very  great  functional  disability  results  if  union 
occurs  with  bony  displacement. 


CHAPTKR   IX 
FRACTURES  OF  THE  HUMERUS 

FRACTURES  OF  THE  UPPER  END  OF  THE  HUMERUS 
Anatomy. — The  clavicle  may  be  felt  throughout  its  entire 
length  from  sternum  to  acromion.  The  acromial  process  of 
the  scapula  articulates  with  the  outer  end  of  the  clavicle.  This 
acromioclavicular  joint  has  an  anteroposterior  direction,  and 
if  the  line  of  this  joint  is  continued  anteriorly,  it  will  pass  down 


Fig.  139. — N'iew  of  bones  of  the  shoulder  from  above.  Notice  acromioclavicular  joint,  its 
relations  to  bicipital  groove  and  coracoid  process.  The  point  of  the  shoulder  is  made  by  the 
great  tubercsity  of  the  humerus. 


the  front  of  the  upper  arm  (see  Fig.  139).  The  outer  edge 
of  the  acromion  is  continuous  downward  and  backward  with 
the  spine  of  the  scapula.  The  great  tuberosity  of  the  humerus 
projects  bevond  the  acromial  process,  and  is  covered  by  the 
deltoid  muscle.  The  point  of  the  shoulder  itself  is  made  by  the 
humerus  and  not  by  the  acromion  (see  Figs.   139,   140). 

130 


EXAMINATION    OF    THE    SHOUIyDER 


131 


Examination  of  the  Shoulder. — The  uninjured  shoulder 
should  be  examined  before  the  injured  shoulder.  In  injuries 
doubtful  in  character,  associated  with  much  swelling  of  the 
shoulder,  and  which  are  painful  upon  gentle  manipulation,  the 
examination  should  be  made  with  the  aid  of  an  anesthetic.  Great 
swelling  suggests  great  trauma ;  absence  of  all  swelling  appreciable 
to  the  eye  suggests  slight  trauma. 

For  the  examination  the  patient  should  be  seated  upon  a 
rather  high  stool,   so  that  the  shoulder  comes  to  an  easy  level 

Coracoid  process.  Clavicle. 


Acromial  process 
of  scapula. 


Head  of  humerus. 


Fig.  140. — Relations  of  bones  to  surfaces  of  shoulder  region.  Great  tuberosity  of  humerus 
projects  beyond  the  acromial  process  of  scapula.  Relations  of  coracoid  to  clavicle  and  head 
of  humerus  (compare  with  Fig.  146). 


for  manipulation.  The  shoulder  should  be  grasped,  so  that  the 
head  of  the  humerus  can  be  felt  between  the  fingers  and  thumb 
of  one  hand  pressed  under  the  spinous  and  acromial  processes. 
The  other  hand  should  grasp  the  flexed  elbow  firmly,  in  order 
to  make  the  necessary  movements  at  the  shoulder-joint  (see 
Fig.  141).  If  the  head  of  the  humerus  is  intact  and  in  its  normal 
place,  it  will  be  felt  to  move  with  the  shaft  of  the  humerus,  as 
upon  the  uninjured  side.  All  the  normal  movements  of  the 
shoulder-joint  should  be  made  passively  and  actively — namely, 


HH 

i^:l|l| 

^^r 

'^il 

^^^Hk' 

VM^H 

^B 

"^ 

mi 

^M 

^^^^^P^l^i;^'  tl 

wl 

■^ 

2U 

Fig.  141.— Examination  of  shoulder.     Method  of  palpating  head  of  humerus  with  thumb  and 
fingers.     Elbow  grasped  by  other  hand. 


Fig.  142. — Examination  of  shoulder.     Movements  of  the  shoulder.     Normal  maximum  abduc- 
tion.    Notice  method  of  grasping  head  of  humerus. 
132 


EXAMINATION    OF    THE    SHOUIyDKR 


133 


the  movements  of  abduction,  adduction,  forward  and  backward 
swing,  and  rotation  (see  Figs.  142,  143,  144).  Those  move- 
ments which  are  painful  and  hmited  should  be  carefully  noted. 
Unless  the  normal  individual  standard  of  movement  is  known, 
as  determined  by  examination  of  the  well  shoulder,  there  can 
be  no  definite  interpretation  of  the  conditions  existing  in  the 
injured    shoulder.     The    condition    of    the    circulation    and    the 


jmk. 

^^gpr^ 

W^ 

kfk 

Ik    \ 

p'M 

/^B 

ji^^Bb^s^P 

m 

J       ^      ~w     / 

In' 

lii^Mi^^'  -*^»^ 

^y 

% 

Fig.  J43. — Examination  of  shoulder.     Maximum  adduction.     The  bend  of  the  elbow,  when 
the  forearm  is  flexed  to  a  right  angle,  comes  to  the  median  line  of  trunk. 


presence  of  paresis  or  paralysis  in  the  limb  should  be  observed. 
The  shaft  of  the  humerus  should  be  measured:  the  measurement 
best  taken  is  the  distance  between  the  edge  of  the  acromial  pro- 
cess and  the  external  condyle  of  the  humerus.  The  patient 
should  be  seated  with  the  elbow  at  the  side  if  possible,  and  flexed 
to  a  right  angle  (see  Fig.  145).  The  forearm  should  rest  on 
the  thigh  of  the  same  side.  The  direction  of  the  long  axis  of  the 
humerus  should  be  carefully  noted. 


134 


FRACTURES    OF    TlIIv    Iir.MIvRUS 


The  coracoid  process  of  the  scapula  in  all  injuries  to  the  shoulder 
should  be  palpated,  for  a  knowledge  of  its  position  assists  in 
locating  the  bead  of  the  humerus  intelligently  (see  Fig.  146). 
The  examiner  should  stand  in  front  of  the  patient,  and  place 
the  left  hand  upon  the  right  shoulder  and  the  right  hand  upon 
the  left  shoulder,  the  hands  being  open.  The  thumb  should 
fall  below  the  clavicle  a  full  finger's-breadth,  when  the  end  of  the 
thumb  will  touch  the  coracoid.     It  is  generally  possible  to  feel 


Fig.    144. — Examination   of    shoulder.      Maximum    outward    rotation.      Notice    position   of 

examining  hands. 


the  coracoid  even  in  very  stout  people  and  when  much  swell- 
ing is  present. 

Diagnosis.— It  is  sometimes  impossible  to  determine  the 
■exact  lesion  following  an  injury  to  the  shoulder.  Anesthesia 
and  the  Rontgen  ray  are  invaluable  aids  to  diagnosis.  It  is  of 
the  first  importance  to  know  whether  the  head  of  the  humerus 
is  in  the  glenoid  cavity  or  whether  it  is  dislocated ;  this  is  deter- 
mined by  palpation  and  by  noting  the  direction  of  the  long  axis 


DIFFERENTIAI^    DIAGNOSIS 


135 


of  the  humerus.  It  is  next  in  importance  to  learn  whether 
there  is  a  fracture  of  the  humerus.  If  the  humeral  head  rotates 
with  the  shaft,  there  is  probably  no  fracture  unless  there  is  one 
with  impaction.  If  the  humeral  head  does  not  rotate  with  the 
shaft,  then  there  is  a  fracture.     If  crepitus  is  present,  the  diag- 


Fig.  145. — Method  of  measur- 
ing the  length  of  the  shaft  of  the 
humerus  from  the  acromial  pro- 
cess to  the  external  condyle. 


Fig.  146. — Examination  of  shoulder.  Palpating 
the  coracoid  processes.  Note  the  position  of  the  hands 
and  thumbs. 


nosis  is  confirmed.     After  injury  to  the  shoulder  the  following 
fracture  lesions  may  be  present,  and  are  to  be  considered: 

Fracture  of  the  anatomical  neck  of  the  humerus. 
Separation  of  the  upper  humeral  epiphysis. 
Fracture  of  the  surgical  neck  of  the  humerus. 


In  any  one  of  these  instances  a  dislocation  of  the  humeral 
"head  from  the  glenoid  cavity  may  exist  and  complicate  the  case. 

Simple  Dislocation  of  the  Himieral  Head,  Subcoracoid 
(see  Fig.  147). — The  attitude  is  characteristic:  the  affected  arm 
is  held  flexed,  with  the  elbow  away  from  the  side  and  the  arm 
rotated  inward.     The  anterior  axillary  fold  is  lowered  upon  the 


136 


FRACTURES   OF    THE    HUMERUS 


iniurcd  side.  The  long  axis  of  the  shaft  of  the  humerus  is  in- 
clined inward.  The  roundness  of  the  shoulder  is  llattened. 
The  acromial  process  is  prominent.  The  head  of  the  humerus 
is  out  of  the  glenoid  cavity,  and  most  often  lies  under  the  coracoid 
process.  The  elbow  can  not  be  brought  in  front  toward  the 
median  line,  nor  can  the  hand  of  the  injured  arm  be  placed  upon 
the  opposite  shoulder.     Active  and  passive  movements  at  the 


Fig.  147.— Dislocation  of  liie  left  shoulder.  Note  the  flat  deltoid.  Prominence  under 
coracoid.  Direction  of  the  long  axis  of  the  humeral  shaft.  Lengthening  of  upper  arm.  Left 
nipple  lowered.     Anterior  axillary  fold  lowered. 


shoulder-joint  are  greatly  restricted.  Measuring  from  the  acro- 
mial process  to  the  external  epicondyle  of  the  humerus,  the 
upper  arm,  in  a  subcoracoid  dislocation,  is  lengthened.  A  soft 
crepitation  may  be  detected  in  manipulating  the  shoulder,  which 
simulates  bony  crepitus. 

Fracture  of  the  Anatomical  Neck  (see  Figs.  148,  149,  150, 
151,152,153). — This  is  rare.  It  occurs  in  elderly  people.  Swell- 
ing of  the  shoulder  is  evident.     Anesthesia  is  necessary  for  a 


SEPARATION    OF    THE    UPPER    EPIPHYSIS  1 37 

careful  examination  with  deep  palpation.  There  is  thickening 
of  the  neck  of  the  bone.  Crepitus  will  be  felt  unless  the  fracture 
is  impacted.  There  will  be  pain  upon  moving  the  shoulder. 
Abnormal  mobility  may  be  felt  high  up  the  shaft  close  to  the 
head  of  the  bone.  This  fracture  lies  wholly  within  the  capsule 
of  the  joint. 

Separation  of  the  Upper  Epiphysis  (see  Figs.  154,  155,  156, 
i57>  158)- — The  separation  of  the  upper  humeral  epiphysis  will 
not  necessarily  open  the  joint  cavity,  for  the  capsular  ligament 


Deform- 


Fig.  148. — Fracture  of  the  anatomical  neck  of  the  left  humerus.  Atrophj-  of  the  shoulder 
muscles.  Deformity  at  the  seat  of  the  fracture,  seen  a  little  below  acromial  process  upon  the 
anterior  surface  of  the  shoulder  just  inside  the  white  line. 


is  firmly  attached  to  the  epiphysis  and  the  synovial  mem- 
brane is  but  loosely  attached  to  the  diaphysis.  The  line  of  the 
separation  of  the  upper  epiphysis  of  the  humerus  begins  on  the 
inner  side  of  the  head  of  the  bone  and  runs  across  almost  hori- 
zontally, rising  toward  the  center  of  the  shaft,  and  ends  in  the 
outer  side  of  the  bone,  so  that  the  epiphysis  includes  the  tuber- 
osities. 

This  happens  to   young  people,   but  never  before   the   sixth 
year  and  never  after  the  twentieth  year.     The  most  frequent 


138 


FKACTl'RES    OF    THK    Hl'MKRUS 


period  is  bct\veen  the  ages  of  nine  and  se\enleen  years.  Or- 
dinarily, the  upper  end  of  the  lower  fragment  projects  forward 
and  inward,  producing  a  characteristic  deformity.  This  injury 
may  occur  either  with  or  without  displacement  of  the  shaft  of 
the  bone,  depending  upon  the  force  causing  the  injury  and  upon 
the  nuiscidar  ])idl.  The  signs  are  a  little  like  those  attending 
a  fracture  of  the  surgical  neck  of  the  humerus.     There  may  be  no 


Fig-.  i4q. — Normal  ri.ijht  shoulder.  Com- 
pare with  figure  150.  Same  case  as  figure 
148. 


Fig.  150. — Fracture  of  the  anatomical 
neck  of  the  left  humerus.  Sharp  deformity 
anteriorly  characteristic.  Compare  with  fig- 
ures 148  and  149. 


displacement  at  first  and  after  a  few  (three)  days  a  distinct  dis- 
placement appears,  especially  if  no  attempt  is  made  to  hold  the 
shoulder  still.  The  displacement  may  be  partial  or  complete. 
Partial  displacement  is  more  common  than  complete.  The  head 
of  the  bone  is  in  the  glenoid  fossa,  but  rotated  by  the  muscles 
attached  to  it  so  that  its  articular  surface  looks  downward.  It 
does  not  rotate  with  the  shaft.  The  crepitus  is  of  a  softer  quality 
than  in  cases  of  fracture — i.    e.,   cartilaginous.     Localized   pain 


\       Clavicle. 


Shaft  of  humerus. 


)Fig.  151.— Fracture  of  high  surgical  or  anatomical  neck  of  humerus.     Recovery  with  useful 
arm.     Slight  limitation  of  movements  only  (X-ray  tracing). 


Shaft  of  humerus. 


Glenoid  cavity 
of  scapula. 


Fig.  152. — Fracture  of  the  anatomical  neck  of  the  humerus  (X-ray  tracing). 


139 


Fig.  153. — Man,  sixty  years  of  age.  Fracture  of  aiiatomica!  neck  of  humerus,  six  months 
previous  to  this  (X-ray  tracing).  Backward  swing  and  abduction  slightly  limited,  otherwise 
normal  movements.     Useful  arm. 


Coracoid 

process.     Clavicle. 

I 


, Acromion. 


Epiphysis. 
Epiphyseal  line. 


f 4 Glenoid  fossa. 


Fig.  154. — Normal  shoulder,  showing  epiphysis  of  upper  end  of  humerus  (X-ray  tracing). 


140 


Fig-  155- — Separation  of  upper  epiphy- 
sis of  the  humerus  immediately  after  the 
accident.  Note,  especially,  position  of  up- 
per arm  and  position  of  head,  and  deep 
crease  in  skin  made  by  the  catching  of  the 
skin  in  the  upper  end  of  the  lower  frag- 
ment.    Same  as  figure  156. 


Fig.  156. — Separation  of  the  upper  epiphy- 
sis of  the  humerus  (left).  Notice  shortening 
of  the  upper  arm.  Unusual  fullness  internal 
and  above  normal  position  for  head.  Same  as 
figure  157. 


F'g-  157- — Separation  of  the  upper  epiphysis  of  the  left  humerus.  Notice  prominence 
below  normal  place  for  humeral  head.  This  prominence  is  made  by  the  upper  end  of  lower 
fragment.    Same  case  as  figure  155. 

141 


Clavicle.        Scapula. 


Fig.  15S. — Fracture  of  high  surgical  neck,  or  separation  of  epiphysis  with  rotation  of  liead 
(X-raj'  tracing  of  figure  155). 


Epiphysis. 


Lower  fragment 
and  callus. 


Fig.    159. — Old    fracture   of   surgical    neck    high    up,  simulating  true   epiphyseal    separation 

(X-ray  tracing). 


142 


Head  of  liu- 
meius. 


Shaft  of  hu- 
merus. 


Fig.  i6o. — High  fracture  of  surgical  neclc,  simulating  separation  of  the  upper  epiphysis  of 
the  humerus.  Displacement  of  lower  fragment  inward.  Old  fracture  unreduced  (X-raj- 
tracing). 


Fig.  i6i. — Fracture  of  the  surgical  neck  (X-raj-  tracing),  showing  ordinary  displacement  of 
the  shaft  of  the  humerus. 


143 


144 


FKACTrRKS    OF    THE    IIUMIvRl'S 


and  swelling  are  present.  A  puckering  of  the  skin,  caused  by 
the  hooking  of  the  lower  fragment  into  the  skin,  is  character- 
istic (see  Fig.  155).  Palpation  reveals  the  upper  end  of  the 
shaft  as  a  cotnparatively  smooth  surface,  unlike  the  end  of  a 
fractured  bone.  The  shoulder  maintains  its  rounder  natural 
appearance.  Grasping  the  head  of  the  humerus  angular  move- 
ment of  the  humeral  shaft  will  fail  to  move  the  head,  whereas 
rotatory  movement  may  move  it.  An  absence  of  shortening  of 
the  upper  arm  means  absence  of  great  displacement  and  untorn 
periosteum.     A  high  lesion  near  the  joint  in  a  young  patient, 


•  —  Head  of  humerus. 


■  —  Shaft  of  humerus. 


Fig.  162. — Fracture  of  the  surgical  neck  of  the  humerus.     Displacement  of  the  shaft  outward. 
Impossible  to  reduce  without  open  incision  (X-ray  tracing)  (Eliot). 


showing  displacement  forward  and  inward  of  the  shaft,  is  very 
suggestive  of  epiphyseal  separation. 

Treatment  of  Separation  of  the  Upper  Epiphysis  of  the 
Humerus. — When  there  is  no  displacement,  immobilization  of 
the  shoulder-joint  is  indicated. 

When  there  is  but  slight  displacement,  firm  pressure  with 
traction  will  ordinarily  correct  the  deformity. 

When  there  is  much  displacement,  reduction  is  often  not  only 
hard  to  effect  but  sometimes  impossible  without  operative  as- 
sistance. 


FRACTURE    OF    TIIU    SURGICAI.    NECK 


H.5 


The  chief  obstacles  of  reduction  are  the  capsule  oi  the 
joint,  the  bands  of  periosteum  or  fascia  or  the  muscles  or  tendon 
of  the  long  head  of  the  biceps  caught  between  the  fragments. 
In  operating  it  may  be  necessary  to  resect  the  head  of  the  bone 
or  to  simply  divide  or  displace  the  parts  preventing  reduction. 
In  almost  no  instance  can  it  be  determined  before  operating 
exactly  what  procedure  will  be  followed. 

Prognosis. — Usually  union  occurs,  if  there  is  no  displacement 
or  onlv  slight  displacement,  without  deformity  and  with  a  func- 


—  Upper  fragment. 
■-   Lower  fraement. 


A 

/    1 


Fig.  163. — Fracture  of  surgical  neck  of  the  humerus.  Same  as  figure  162  after  reduction 
by  open  incision  and  wiring  with  silver  wire.  Recovery  as  to  motion  complete  (X-ray  tracing) 
(Eliot). 


tionally  useful  shoulder.  If  there  is  great  displacement,  de- 
formity and  impairment  of  motion  will  persist  if  reduction  is  not 
complete.  The  growth  of  the  humerus  may  be  seriously  inter- 
fered with  if  an  unreduced  displacement  is  allowed  to  remain 
untreated. 

Fracture  of  the  Surgical  Neck  (see  Figs.  i6i,  162,  163). — 
Any  fracture  below  the  epiphyseal  line  of  the  upper  end  of  the 
humerus  and  well  within  the  upper  fourth  of  the  shaft  of  the 
bone  may,  for  all  practical  purposes,  be  regarded  as  a  fracture 
of  the  surgical  neck  of  the  humerus.     Fracture  of  the  surgical 


146  KKACTIRES    OF    THE    IH  Ml-KlS 

neck  is  tlic  common  rraclurc  dI  the  iii)])er  ciul  of  the  liunicnis. 
iM'acturc  of  Lhe  aiuUomiciil  neck  is  most  often  seen  in  tlie  ageck 
vSeparation  of  the  npper  humeral   epiphysis  occurs   in   youth. 

The  head  of  the  bone  is  foiuid  in  the  .i^lenoid  cavity.  Passive 
movements  arc  associated  Avith  pain,  and  ehcit  crepitus  and 
abnormal  mobiht^■  at  the  seat  of  fracture,  providetk  of  course, 
the  fracture  is  not  impacted.  The  arm  is  shghth'  shortened. 
The  arm  is  hekl  flexed,  with  the  elbow  at  the  side. 

If  after  an  injurv  to  the  shoulder  no  jiositive  e\idences  of 
fracture  or  dislocation  exist,  and  there  are  tenderness  and  localized 
swelling  about  the  joint,  and  motion  is  painful,  it  is  probable 
that  simply  a  contusion  exists. 

Treatment. — Fracture  of  the  Anatomical  and  the  Surgical 
Neck  ami  Separation  of  the  Upper  Humeral  Epiphysis. — The  im- 
portance of  these  lesions  demands,  as  has  been  said,  an  examina- 
tion with  the  aid  of  an  anesthetic.  It  is  even  much  more  im- 
portant, however,  that  the  first  retentive  dressing  be  applied  with 
the  assistance  of  an  anesthetic.  Traction,  countertraction,  and 
manipulation  will  secure  coaptation  of  the  fragments.  To 
hold  these  fragments  securely  is  difficult.  To  hold  a  separation 
of  the  upper  epiphysis  in  position  may  be  impossible  without 
operative  assistance.  To  hold  any  one  of  these  fractures  without 
operative  interference  may  be  impossible. 

The  following  is  the  best  and  simplest  method  of  treatment : 
The  upper  arm,  shoulder,  and  trunk  should  be  thoroughly  pow- 
dered. The  hand,  forearm,  and  elbow  should  be  bandaged 
evenly,  smoothly,  and  firmly  with  a  bandage  of  flannel — not 
cut  on  the  bias.  A  V-shaped  pad  (with  the  apex  of  the  V  in  the 
axilla)  constructed  of  sheet  wadding  with  cardboard  outside 
and  covered  with  cotton  cloth,  should  be  placed  in  the  axilla 
of  the  injured  side  (see  Fig.  164).  This  pad  is  firm,  and  fitted 
to  the  trunk  in  order  to  support  the  inner  side  of  the  upper  arm 
(see  Fig.  165).  If  thought  wise,  a  thin  coaptation  splint  may 
be  placed  between  this  pad  and  the  inner  side  of  the  upper  arm 
for  more  direct  support.  The  forearm  is  held  flexed.  The 
shoulder  is  now  well  padded  with  one  layer  of  sheet  wadding. 
A  plaster-of-Paris  shoulder-cap  is  applied  so  as  to  cover  the 
whole  shoulder,  the  anterior  and  posterior  aspects  of  the  chest, 


Fijf.  164. — FracUue  of  the  upper  end  of  the  humerus.     Note  hand,  forearm,  and  elbow  ban- 
daged evenly  and  without  compression  ;  axillarj-  pad  and  strap. 


Fig.  165. — Fracture  of  the  upper  end  or  shaft  of  the  humerus.     Posterior  view.     Note  bandage 
to  forearm  and  elbow  ;  axillary  pad  and  strap.     Note  shape  of  axillary  pad. 

147 


148 


I'RACTrRES    OF    Tin-:    IHMIvRrS 


and  the  outer  side  of  the  u]:)per  arm  down  to  the  external  condyle 
of  the  humerus  (see  Fig.  166).  This  shoulder-caj-)  is  made  of 
washed  crinoline,  six  la\'ers  thick,  into  \vhich  has  been  rubbed 
plaster-of- Paris  cream.  Its  exact  shape  and  extent  are  seen 
in  the  plates.  A  gauze  bandage  encircling  the  trunk,  arms,  and 
shoulders  should  be  used,  in  order  to  hold  the  upper  arm  at  the 
side  and  closely  applied  to  the  coaptation  splint  and  the  axillary 
pad.   and   in  order  to  secure  the   shoulder-pad   firmly  in  place. 


Fig.  166. — Fracture  al  upper  end  of  ihe 
humerus.  Note  hand,  forearm,  and  elbow 
bandaged;  axillary  pad  and  strap,  plaster- 
of-Paris  shoulder-cap,  sling. 


FIl;.  1117.  —  I'"racture  at  upper  end  of  hu- 
merus. Arm  and  elbow  bandaged.  A.xil- 
lary  pad  and  shoulder-cap  in  position.  Ap- 
plication of  circular  bandage  to  trunk  and 
shoulder.     Sling  not  shown. 


Often  better  than  the  plain  gauze  bandage  is  a  roller  bandage 
of  unwashed  crinoline,  which  is  applied  just  after  dipping  it  in 
lukewarm  water  (see  Fig.  167).  The  starch  of  the  crinoline 
bandage  after  being  wet,  stiffens  the  crinoline  as  it  dries  and 
makes  a  particularly  firm  and  efficient  dressing.  A  towel  folded 
thin  or  a  piece  of  compress  cloth  should  be  placed  against  the 
trunk  upon  the  well  side.  Against  this  the  circular  turns  of 
the  bandage  rest,  thus  causing  less  discomfort  to  the  patient  than 
if  they  bear  directly  upon  the  chest.     The  forearm  is  supported 


FRACTURKvS    OF    THK    UPPIvR    F^ND    OF    TllF    HUMIvRUS  1 49 

by  a  cravat  sling  (see  Fig.  i66).  By  this  method  of  immobiliza- 
tion no  active  traction  is  exerted  upon  the  lower  fragment. 
The  weight  of  the  arm,  being  unsupported  at  the  elbow,  exerts 
slight  traction. 

On  account  of  the  absence  of  active  traction,  ambulatory 
apparatus  can  not  hold  a  fracture  of  the  shoulder  properly  if 
there  is  much  displacement;  particularly  if  the  fracture  is  ob- 
lique. Ambulatory  apparatus  can  modify  muscular  action,  in- 
sure quiet  and  rest  to  the  part,  and,  except  in  the  instances  just 
noted,  approximately  maintain  the  position  secured  by  manip- 
ulation and  traction  and  countertraction.  On  account  of  its 
limitations,  therefore,  it  is  important  that  apparatus  should 
be  removed  at  regular  and  frequent  intervals  and  that  the  whole 
shoulder  should  be  examined  in  order  »to  determine  errors  in 
position  and,  if  possible,  to  correct  them. 

After-care  of  a  Fracture  of  the  Shoulder. — Ordinarily,  the  great 
swelling  associated  with  this  injury  disappears  in  two  weeks. 
As  the  swelling  subsides,  the  normal  contour  of  the  shoulder 
becomes  apparent  again.  It  is  necessary,  therefore,  to  alter 
the  shoulder  splint  and  to  apply  a  fresh  one.  When  the  patient 
wearing  a  shoulder-cap  lies  down,  there  is  a  tendency  for  the 
shoulder-cap  to  ride  up  and  away  from  the  shoulder.  This 
can  be  guarded  against  by  carrying  the  retaining  bandage  under 
the  firm  axillary  pad  and  well  over  the  shoulder.  Pressure 
points  should  be  carefully  watched,  and  the  pressure  removed. 
In  the  course  of  the  treatment  of  a  single  case  this  change  of  dress- 
ing will  have  to  be  made  two  or  three  times.  Union  will  be 
firm  in  from  three  to  four  weeks.  As  soon  as  union  is  firm,  all 
splints  may  be  omitted.  The  forearm  should  then  be  held  by 
a  sling  supporting  the  wrist.  At  night  it  will  be  wise  to  apply 
a  single  swathe  the  first  week  after  the  apparatus  is  left  oft'  in 
order  to  avoid  undue  motion  at  the  shoulder  during  sleep.  In 
these  injuries  about  the  shoulder-joint  passive  motion  should 
be  made  rather  early.  At  the  end  of  two  weeks  or  two  weeks 
and  a  half  repair  will  have  proceeded  far  enough  to  allow  of  the 
gentlest  movement  at  the  shoulder  without  causing  any  displace- 
ment of  fragments.  The  sooner  these  gentle  movements  can 
be  resumed  at  regular  and  short  intervals,  the  more  rapidly  the 


I50 


FRACTiRiiis  OF  Tin-:   lITMHRrS 


shoulder  will  improve.      The  common  occurrence  of  a  periarth- 
ritis after  an   iiijur\-   to   the   shoulder  emphasizes  the   necessity 


Fig.  168. — Young  adult.     Fracture  of  the  surgical  neck  of  the  humerus  (X-ray  tracing,  four 
years  after  the  accident).     Ahduction  and  rotation  very  slightly  limited.     Useful  arm. 


A .   Head  of 

humerus. 


\-    Shaft  of 
'  humerus. 


Fig.  169.— Fracture.  Man  fifty-five  years  of  age.  High  surgical  neck  of  humerus.  At  the 
end  of  five  >ears  recoverv  with  very  slight  limitation  of  motion  in  all  directions.  Abduction 
is  limited  nearly  one-half.  I'seful  shoulder  (X-ray  tracing.  Massachusetts  (leneral  Hospital, 
1 02 1 1. 


of  massage.      It  shouM  be  begun  as  early  as  the  second  or  third 
week. 


FRACTURES    OF    THE    UPPER    END    OF    THE    HUMERUS  151 

Prognosis  and  Result. — In  young  subjects  a  useful  arm 
will  result  (see  Fig.  168).  At  first,  if  there  is  great  difliculty 
in  maintaining  the  reduction  of  the  fragments,  the  surgeon 
will  expect  a  poor  result,  but  if  he  persists  in  efforts  at  retention 
and  uses  passive  motion  early,  gradually  the  movements  of  the 
arm  will  return  and  to  a  surprising  degree.  In  people  past 
middle  life  there  usually  is  a  little  shortening  of  the  upper  arm 
and  impairment  in  some  few  of  movements  of  the  shoulder,  as 
in  abduction  and  external  rotation.  In  individuals  over  fifty 
years  old,  excepting  those  with  rheumatism,  a  useful  but  not  a 
strong  shoulder  results  (see  Fig.   169). 

The  Prognosis  in  Separations  of  the  Epiphysis:  Bony  union 
is  to  be  expected.  If  there  is  little  or  no  displacement  of  frag- 
ments, complete  restoration  of  function  will  result.  If  there 
is  some  deformity  remaining  after  consolidation  of  the  injury,  the 
usefulness  of  the  shoulder  is  ultimately  and  usually  restored. 
The  deformity  becomes  less  apparent  as  the  sharp  bony  corners 
are  smoothed  off  by  the  newly  forming  callus.  It  is  not  to  be 
forgotten  in  considering  the  prognosis  after  all  shoulder  injuries 
that  much  of  the  persisting  disability  may  result  from  too  pro- 
longed immobilization  of  the  arm,  even  though  bony  displace- 
ment may  not  have  been  very  great.  The  growth  of  the  shaft 
of  the  humerus  in  length  proceeds  largely  from  the  upper  epiph- 
ysis. It  has  been  thought  by  many  that  an  arrest  of  growth 
of  the  humerus  will  follow  separation  of  this  upper  epiphysis. 
It  has  been  reported  to  have  occurred  in  eight  cases  but  in  no 
others.  In  several  of  these  cases  the  injury  to  the  shoulder 
was  thought  at  the  time  to  have  been  a  simple  contusion  or 
sprain.  A  loss  of  growth  is  not  likely  to  occur,  but  may  follow 
injury  to  the  upper  humeral  epiphysis. 

Oblique  Fracture  of  the  Surgical  Neck  with  Great  Displacement. — 
This  fracture  can  sometimes  be  held  bv  placing  the  patient  in 
bed  upon  the  back  and  making  direct  traction  to  the  upper  arm 
and  countertraction  upon  the  shoulder  by  weight  and  pulley. 
If  the  fracture  can  not  be  easily  held  reduced,  it  will  be  wise  to 
make  the  closed  fracture  an  open  and  to  unite  the  two  fragments 
by  suture  (see  Figs.  162,  163). 

Fracture  of  the  Shoulder,   Surgical  or  Anatomical  Neck   of  the 


152  FKACTl'KI'S    OF    TIlIv    IlTMERl'S 

Ilidiicnis,  or  Scpa>a{io)i  oj  the  I  pf^cr  J-^pif^liysis  oj  the  HiDiicrux, 
Together  with  a  Disloeatioii  0/  the  l' (^{^er  l-'raq))u-)it. — The  head 
of  the  humerus  is  found  in  an  iiiniatural  position  and  it  fails 
to  move  when  the  arm  is  rotated.  This  is  generally  thought 
to  be  an  unusual  aeeident,  but  h\  earcful  examination  manv 
of  these  cases  may  be  detected.  During  the  attempt  at  reduc- 
tion of  a  dislocated  shoulder,  fracture  of  the  humeral  shaft  is 
liable  to  occur.  Among  many  cases  of  fracture  of  the  surgical 
neck  the  fracture  occurred  fifty-nine  times  while  an  attempt  at 
reduction  of  a  dislocation  of  the  shoulder  was  being  made. 

Treatment. — Obviously,  attempts  at  reduction  by  manipula- 
tion in  the  usual  way  will  meet  with  failure.  An  attempt  should 
always  be  made  to  reduce  the  dislocation  by  abduction  and  trac- 
tion upon  the  upper  arm  and  pressure  with  the  hand  upon  the 
loose  head  in  the  axilla.  It  may  be  possible  to  reduce  the  disloca- 
tion in  this  manner.  If  this  method  fails,  an  attempt  should  be 
made  to  reduce  the  dislocated  head  by  open  incision  (arthrotomv) 
and  manipulation  of  the  upper  fragment  assisted  by  the  Mc- 
Burney-Porter  hook  manocuver.  If  this  attempt  is  successful, 
the  shaft  should  be  sutured,  with  an  absorbable  suture  or  fine 
silver  wire,  to  the  reduced  head,  and  the  shoulder  treated  as  if  a 
closed  fracture  existed. 

If  it  is  impossible  to  reduce  the  dislocated  head  or  if  the  head 
is  much  comminuted,  it  will  be  necessary  to  excise  it. 

If  operative  interference  has  been  decided  upon,  it  is  best  to 
defer  the  operation  until  the  acute  symptoms  have  subsided 
and  the  damaged  tissues  have  recovered  themselves.  It  is  the 
result  of  experience  that  operation  through  acutely  damaged 
tissues  is  unwise.  The  vitality  of  the  tissues  is  lessened  by 
trauma,  hence  the  resistance  to  infection  is  temporarily  impaired. 

If  the  reduced  head  of  the  humerus  becomes  necrosed  and 
abscesses  form  about  the  joint,  an  unusual  occurrence,  the  head 
of  the  bone  should  be  immediately  excised. 

The  After-treatment  of  Operated  Cases. — If  reduction  and  sutur- 
ing have  been  accomplished,  passive  motion  should  not  be  at- 
tempted until  the  repair  at  the  seat  of  fracture  is  well  under 
way.  This  will  be  about  the  second  week.  Then  gentle  move- 
ment may  be  made  and  gradually  increased. 


FRACTURKS    OF    TIIi;    SHAFT    OF    TIII1;    HUMURUS  1,53 

If  resection  has  been  performed,  passive  motion  should  be 
gently  begun  almost  immediately — i.  e.,  within  the  first  forty- 
eight  hours — and  persistently  continued.  The  muscles  of  the 
shoulder  should  be  massaged  and  treated  by  electricity.  Ab- 
duction should  not  be  attempted  to  any  great  extent  for  some 
weeks  after  the  operation  for  fear  of  displacing  the  upper  end 
of  the  humerus.  The  final  results  following  reduction  and  sutur- 
ing have  been,  as  a  rule,  excellent,  useful  arms  resulting  in  most 
cases.  The  results  following  excision  are  only  fairly  satisfactory. 
If  the  proper  amount  of  bone  has  been  removed,  ankylosis  will 
not  occur.  If  too  much  bone  has  been  removed,  a  dangling  or 
flail  joint  will  result.     An  excision  is  to  be  avoided  if  possible. 


FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS 
Fracture  of  the  shaft  of  the  humerus  may  occur  at  any  point 
between  the  surgical  neck  and  the  condyles  (see  Fig.  170).  Its 
common  seat  is  at  the  middle  or  in  the  lower  third  of  the  bone 
(see  Fig.  171).  The  twisting  force  exercised  in  the  breaking 
up  of  adhesions  in  and  about  the  shoulder-joint  will  often  frac- 
ture a  humeral  shaft  obliquely.  The  strength  test  of  the  arms,  as 
seen  in  the  illustration,  has  been  the  cause  of  spiral  fracture  of 
the  humerus  (see  Figs.  172,  173). 

Symptoms. — The  symptoms  are  readily  recognized.  They 
are  swelling  at  the  seat  of  fracture,  pain,  crepitus,  abnormal 
motion,  and  ecchymoses.  Paralysis  of  the  musculospiral  nerve 
may  occur,  with  the  characteristic  wrist-drop.  Ordinarily,  the 
attention  of  both  the  patient  and  the  surgeon  is  so  occupied 
with  the  fracture  of  the  bone  and  its  associated  loss  of  movement 
that  loss  of  power  and  sensation,  because  of  involvement  of  the 
nerve,  goes  unrecognized.  If  injury  to  the  musculospiral  nerve 
is  not  recognized  at  the  outset,  it  may  be  overlooked  until  the 
splints  are  removed.  The  exact  duration  and  the  cause  of  the 
paralysis  can  not  then  be  readily  ascertained.  The  patient  may 
wrongly  attribute  the  paralysis  to  the  pressure  of  the  splints. 
Very  rarely,  injury  or  pressure  upon  the  large  vessels  of  the  arm 
is  met  with.  Damage  to  the  artery  will  be  suggested  by  weak 
or  absent  pulse  at  the  wrist  or  by  local  evidences  of  hemorrhage. 


Shaft  of  luinienis,  upper 
Iraafiiieiit. 


Shaft  of  humerus,  lower 
fragment. 

Fig.  i7o.-Fraclure  of  shaft  of  humerus,  high.     Displacement  of  lower  end  of  upper  frau 
ment  inward  (X-ra.v  tracing). 


Shaft  of  humerus. 


Radiu 


Shaft  of  humerus,  upper 
fragment. 


Ulna. 


Fig,  I7i.-Fracture  of  the  shaft  of  the  himierus  in  lower  thinl.     Displacement  of  both  frag- 
ments forward  (X-ray  tracing). 


'54 


Fio-.  172.— Trial'of  strength  of  arms  resulting  sometimes  in  spiral  fracture  of  the  humerus 
(Monks).     See  figure  173. 


Fig.  173.— Illustrating  spiral  fracture  of  humerus  (Monks).     See  figure  172. 


155 


i.s6 


KKACTTRHS    OF    Tlllv    HUMERI'S 


A  swelling  appearing  suddenly,  greater  than  that  which  would 
appear  from  the  laceration  of  soft  tissues  alone,  should  suggest 
rupture  of  large  vessels.  Measurement  of  the  humerus  should 
be  made  from  the  edge  of  the  acromial  process  to  the  external 


Fig.  174. —  Longitudinal  fracture  of  shaft  of  humerus  into  the  joint.     Displacement  of  smaller 
fragment  backward.     Note  space  between  fragment  and  shaft.     Arm  extended. 


condyle  of  the  humerus   (see  Fig.    145).     The  amount  of  over- 
lapping of  the  fragments  will  be  shown  by  this  measurement. 

Treatment. — For  purposes  of  treatment,  fractures  of  the  shaft 
mav  be  grouped  into  those  with  little  or  no  displacement  and 


TREATMENT  or  FRACTURES  OF  THE  SHAFT        1,57 

those  with  considerable  displacement  and  dilTicult  of  retentifjn 
after  reduction.  The  fracture  should  be  reduced  by  traction 
upon  the  condyles  of  the  humerus  and  countertraction  upon 
the  upper  arm  and  by  manipulation  of  the  fractured  bones. 
Treatment  of  Fractures  of  the  Shaft  of  the  Humerus  with  Little 


Fig.  175.— Same  as  figure  174.     Note  the  disappearance  of  space  between  fragments  with  cor- 
rection of  deformity  upon  flexing  forearm.     Position  reduces  the  fracture. 


or  no  Displacement  (see  Figs.  176,  177). — The  following  materials 
are  needed  for  the  apparatus  to  be  used:  Ordinary  dusting- 
powder, — which  is  powdered  oxid  of  zinc  and  powdered  starch, 
equal  parts;  a  bandage  of  Shaker  flannel  three  inches  wide,  not 
cut  on  the  bias ;  an  axillary  pad  made  with  several  layers  of  sheet 


Fi};.  176. — Fracture  of  the  shaft  of  the  humerus.     Note  bandage  to  hand,  forearm,  and  elbow, 
axillary  pad  and  straj) ;  coaptation  splints  and  sling.     Bandage  does  not  cover  fracture. 


'■'J?-  177- — I'racture  of  the  shaft  of  the  humerus.  Note  bandage  to  hand,  forearm,  and 
elb(j\v ;  adhesive-plaster  swathe  holding  arm  upon  axillary  pad  and  covering  coaptation 
splints.     Sling. 

158 


TREATMENT    OF    FRACTURES    (^F    'rillC    SHAFT 


'59 


wadding  covered  with  a  folded  piece  of  pasteboard,  and  the  whole 
inclosed  in  cotton  cloth  stitched  at  the  edges;  the  pad  is  V-shaped, 
and  long  enough  to  extend  from  the  apex  of  the  axilla  to  just 
above  the  internal  condyle  of  the  humerus;  it  is  broad  enough  to 
support  the  upper  arm  comfortably  and  securely;  the  lower 
part  of  the  pad  is  about  three  inches  thick  (see  Fig.  178),  so  as 
to  support  the  arm  only  a  trifle  abducted  from  the  side — that 
is,  just  away  from  the  perpendicular.  If  the  axillary  pad  is 
too  short,  there  is  danger  of  causing  an  outward  bowing  of  the 


Fig.  178. — Space  to  be  filled  by  axillary 
pad  between  arm  and  side  in  fracture  of 
humerus. 


Fig.  179. — Coaptation  splint  seen  flat 
and  in  section.  Made  by  laying  thin  wood 
on  adhesive  plaster  and  splitting  with  knife. 


humerus  (see  Fig.  180).  Two  straps  are  attached  to  the  upper 
corners  of  the  apex  of  the  V-shaped  pad  long  enough  to  surround 
the  body  and  go  over  the  opposite  shoulder.  These  straps  hold  the 
pad  in  position.  The  remaining  apparatus  consists  of  two  or  three 
thin  coaptation  splints  for  application  to  the  upper  arm ;  these  are 
made  readil}^  by  laying  thin  splint  wood  upon  adhesive  plaster, 
and  splitting  the  wood  longitudinally  (see  Fig.  1 79) ;  three  adhesive 
straps  two  inches  wide  to  hold  the  coaptation  splints;  an  ad- 
hesive plaster  swathe  wide  enough  to  extend  from  the  acromion 
tip  to  the  external  condyle,   and  long  enough  to  surround  the 


i6o 


FRACTl'RES    OF    Till-     lUMIvRVS 


body  and  upper  arm;  a  cravat  sling;  a  thin  towel  or  piece  of 
compress  cloth  for  the  forearm  to  rest  upon.  All  these  articles 
should  be  in  readiness. 

Etherization  of  the  patient  will  rarel}-  be  necessary.  In  cases 
of  nervous  and  sensitive  women  and  unmanageable  young  chil- 
dren it  will  be  wise  to  use  an  anesthetic.  The  whole  upper 
extremity,  axilla,  and  chest  should  be  washed  with  soap  and 
water,  thoroughlv  dried,  and  dusted  with  powder;  then  the 
reduced  fracture  is  held   in  position   by  an   assistant  while   the 


Fig.  i8o. — Showing  effect 
(bowing  outward)  of  too  short 
an  axillary  pad  upon  a  fracture 
of  the  shaft  of  the  humerus. 


Fig.  i8i.— High  fracture  of  the  shaft  of  the  hu- 
merus. A  common  and  improper  use  of  an  internal 
right-angle  splint. 


apparatus  is  being  applied.  The  hand,  forearm,  and  elbow 
should  be  snugly  and  evenly  covered  by  the  flannel  bandage 
(see  Fig.  164).  The  upper  arm  should  be  surrounded  by  the 
coaptation  splints,  held  in  place  by  the  three  straps  of  adhesive 
plaster,  so  as  to  secure  the  fractured  bone  perfectly  (see  Fig. 
176).  The  axillary  pad  should  be  placed  in  the  axilla  and  held 
by  the  straps  passed  over  the  opposite  shoulder  and  under  the 
opposite  axilla.  The  upper  arm  should  rest  comfortably  upon 
the  pad.     To  prevent  chafing,  the  thin  towel  or  compress  cloth 


TREATMENT  OV    FRACTURES  OV    THE  SHAFT         l6r 

should  be  placed  beneath  the  forearm  where  it  toiiehes  the  bod\'. 
The  plaster  swathe  should  then  be  applied  over  the  arm  to  the 
body,  so  as  to  encircle  completely  the  trunk  (see  Fig.  177).  Thus 
the  arm  is  absolutely  fixed  to  the  axillary  pad  and  side.  The 
wrist  should  be  supported  in  a  cravat  sling  passed  around  the 
neck.  The  elbow  is  left  unsupported.  The  weight  of  the  upper 
extremity  will  thus  tend  to  exert  slight  downward  traction 
upon  the  lower  fragment  of  the  humerus.  Under  no  circum- 
stances should  an  ordinary  broad  sling  be  used,  because  of  the 
danger  of  making  upward  pressure  upon  the  forearm  and  elbow 
and  so  pushing  up  the  lower  fragment  of  the  humerus.  The 
elbow-joint  should  not  be  immobilized  for  the  reason  that  it 
would  then  be  much  more  difficult  to  hold  the  seat  of  fracture 
fixed.  With  the  elbow-joint  fixed,  the  lower  arm  of  the  lever 
is  greatly  increased,  and  instead  of  movement  of  the  forearm 
taking  place  at  the  elbow-joint  it  would  take  place  at  the  seat 
of  fracture.  Fractures  of  the  shaft  of  the  humerus  are  frequentlv 
treated  by  an  internal  angular  splint  and  coaptation  splints,  the 
upper  ends  of  the  splints  barely  reaching  the  fracture,  or,  at 
best,  being  an  inch  or  two  above  it  (see  Fig.  181).  When  the 
fracture  of  the  bone  is  within  the  lower  third  of  the  shaft,  then 
and  then  only  should  an  internal  angular  splint  be  used  in  con- 
nection with  coaptation  splints. 

After-treatment. — The  patient  should  be  seen  each  dav  for 
the  first  three  days  in  order  that  the  surgeon  may  be  informed 
as  to  the  exact  condition  of  the  parts.  There  mav  be  undue 
pressure.  The  patient  may  be  uncomfortable.  The  splints 
may  need  readjusting.  Attention  to  little  details  of  discom- 
fort is  important.  The  dressing  should  be  reapplied  with  great 
care  once  each  week.  The  parts  covered  by  splints  should  at 
each  dressing  be  carefully  inspected  to  detect  any  points  of  undue 
pressure,  indicated  by  reddening  of  the  skin.  If  these  are  dis- 
covered, they  should  be  washed  with  alcohol  and  covered  with 
flexible  collodion  or  a  drying  powder.  The  undue  pressure  should 
be  removed  by  shifting  the  padding.  Union  will  be  found  to 
be  firm  after  about  three  or  four  weeks.  As  soon  as  union  is 
solid, — at  the  end  of  four  or  five  weeks, — the  swathe  may  be 
omitted,  the  coaptation  splints  alone  being  a  sufficient  support. 


1 62  FRACTURES    OF    TIM'     IirMERL'S 

After  about  five  ^veeks  or  five  weeks  and  a  half  all  support  may 
be  removed  from  the  arm.  The  arm  is  then  put  in  the  sleeve 
of  the  clothes,  and  the  Avrist  supported  by  a  sling.  After  eight 
weeks  the  sling  mav  be  discarded  and  moderate  and  careful  use 
of  the  limb  in  light  movements  be  indulged  in. 

Fracture  oj  the  Shaft  of  the  Humerus  with  Considerable  Dis- 
placement.— Obviously,  the  method  described  for  the  treat- 
ment of  fractures  without  great  displacement  will  be  of  com- 
parativelv  little  value.  Occasionally,  it  will  be  found  that  this 
method  will  hold  even  greatly  displaced  fractures;  it  should 
then  be  used.  The  ideally  perfect  method  for  such  cases  is 
traction  and  countertraction  upon  the  arm  with  the  patient 
lying  on  the  back  in  bed.  Coaptation  splints  should  be  used, 
as  in  simple  uncomplicated  fractures.  If  all  methods  fail  to 
hold  the  fragments  reduced,  open  incision,  reduction  of  the 
displacement,  and  suturing  of  the  fragments  are  indicated. 

The  plaster-of-Paris  splint,  applied  with  the  plaster  roller  to 
the  forearm  and  arm,  and  the  spica  bandage  to  the  shoulder 
and  chest  are  often  efficient  hi  these  difficult  cases.  In  the 
application  of  this  splint  it  is  of  supreme  importance  that  an 
assistant  hold  the  arm  so  that  the  alinement  of  the  bones  re- 
mains perfect.  The  assistant  who  holds  the  arm  should  have 
nothing  else  to  do.  Before  applying  the  plaster-of-Paris  splint 
it  is  often  advisable  to  apply  thin  coaptation  splints  at  the  seat 
of  fracture  to  give  additional  strength  to  the  splint.  With  these 
coaptation  splints  in  use  a  lighter  plaster  splint  may  be  applied 
without  sacrificing  strength.  A  narrow  cotton  swathe  about 
the  bodv  and  arm  should  steady  the  upper  extremity.  The 
wrist  should  be  supported  by  a  cravat  sling. 

The  after-care  of  a  case  treated  by  the  plaster  splint  will  be 
similar  to  that  following  any  other  treatment  after  union  has 
occurred.  The  plaster  may  be  left  in  situ  for  four  weeks;  then, 
ordinarily,  repair  will  be  found  so  far  advanced  that  the  plaster 
splint  may  be  dispensed  with  and  the  ordinary  coaptation  splints 
and  swathe  may  be  used.  If  the  plaster  splint  has  proved  com- 
fortable, it  may  be  split  and  reapplied. 

Massage  and  Passive  Motion :  In  view  of  the  possibility  of  non- 
union of  this  fracture,  it  will  be  wise  not  to  begin  massage  until 


TREATMENT  OF  FRACTURES  OV    THE  SHAFT        16,3 

union  has  begun.  Passive  motion  to  the  shoulder  and  elbow 
should  be  gently  made  at  as  early  a  date  as  possible,  with  due 
consideration  to  the  condition  of  repair  in  the  fracture.  If  at 
the  end  of  three  weeks  union  is  found  to  have  begun,  it  will  be 
wise  to  move  the  shoulder  and  elbow  gently  by  passive  motion. 
The  seat  of  fracture  should  be  cautiously  guarded  against  move- 
ment during  these  gentle  manipulations.     A  little  gentle  passive 


"ig.  182. — Case:  Fracture  of  the  shaft  of  the  left  humerus.     Fraciuie  united.     Note  atrophy 
of  upper  arm,  including  deltoid.     Loss  of  muscular  contour  very  apparent. 


movement  of  this  sort  repeated  occasionally  during  the  process 
of  repair  will  assist  very  considerably  in  the  restoration  of  the 
functional  usefulness  of  the  shoulder  and  elbow,  which  so  often 
become  stiff  from  immobilization. 

Prognosis. — Ordinarily,  union  occurs  readily  in  from  four 
to  six  weeks.  In  childhood  union  is  quite  solid  in  from  three 
to  five  weeks.  Fractures  of  this  bone  are  more  likelv  to  be 
followed  by  nonunion  than  fracture  of  any  other  bone  in  the 


164 


FRACTrRP:S    OK    Till'     IIlMlvRlS 


b()d\-.  The  presence  of  abnorni-.il  niobiliu-  after  a  considerable 
time  (three  months)  has  elapsed  is  the  si(;n  of  nonunion  by  bone. 
Considerable  muscnlar  atrophy  follows  this  fracture  (see  lug. 
182).  Upon  using  the  arm  again  and  bv  massage  the  size  of 
the  arm  is,  in  a  great  treasure,  restored.  The  stiffness  of  the 
shoulder  and  elbow  \vhich  is  sometimes  associated  with  this  in- 
jury is  due  to  long  immobilization  without  passive  motion. 

J-'raciiirc  of  the  shaft  of  the  hiiuiems  soiuetinies  occurs  in  the  }iew- 
honi  din-ing  delivery  or  afterward.  The  arm  is  best  immobilized 
by  thin  coaptation  splints.  These  splints  may  be  as  thin  as 
six  thicknesses  of  ordinary  letter  paper,  and  may  be  made  of 
cardboard.     The   humerus   is  completely   surrounded   by   them. 


Fig.  183. — Relations'  of  niusculospirai  nerve  on  onler  siile  of  arm  (from  clisseclecl  speci- 
men) :  a,  Clavicle  ;  d,  deltoid  ;  c,  pectoralis  major;  d,  biceps  ;  e,  brachialis  anticus  ;_/,  triceps; 
.?■,  muscnlospiral  nerve. 


They  are  held'  firmly  by  adhesive-plaster  straps.  If  they  are 
cut  the  right  length  and  width,  they  may  be  applied  most  effi- 
ciently without  padding.  A  liberal  amount  of  drying  powder 
should  be  rubbed  on  the  arm  and  chest.  A  piece  of  compress 
cloth  should  be  placed  on  the  side  of  the  chest  under  the  injured 
arm,  to  prevent  chafing.  The  upper  arm  is  then  held  to  the 
side  of  the  chest  by  a  gauze  or  other  cloth  swathe.  Repair 
is  rapid.  Union  is  firm  in  about  three  weeks.  Fracture  of  the 
humerus  in  the  newborn  is  sometimes  associated  with  obstetrical 
paralysis  of  the  upper  extremity.  This  obstetrical  paralysis 
should  not  be  confounded  with  muscnlospiral  paralysis. 

The  Musculospiral  Nerve  in  Fracture  of  the  Humerus. — 
The   musculospiral   nerve   may   be   involved   in   fracture   of  the 


MUSCULOSPIRAL    NKRVK    INVOLVlCMIvNT  1 6,5 

humeral  shaft,  particularly  if  the  fracture  is  at  the  middle  or 
in  the  lower  third  of  the  bone.  The  nerve  lies  in  the  musculo- 
spiral  groove  of  the  humerus.  It  leaves  the  bone  a  little  below 
the  junction  of  the  middle  and  lower  thirds  of  the  arm  (see  Fig. 
183).  The  nerve  may  be  involved  primarily  at  the  time  of  the 
accident  by  the  contusion  or  laceration  caused  by  the  original 
violence  or  by  the  pressure  of  bony  fragments.  The  nerve  may 
also  be  involved  secondarily  by  the  pressure  of  the  bony  callus 
or  of  the  cicatricial  tissue  of  the  soft  parts. 

Symptoms. — Contusion    of    the    musculospiral    nerve    may  be 
slight  or  severe.     If  slight,  there  will  be  pain  at  the  injured  place, 


Fig.  184.— Double  fracture  of  humeral  shaft.  Immediate  musculospiral  paralysis.  Union 
of  bones  in  six  weeks.  Operation  to  free  nerve  from  lower  fragment.  Sensation  and  motion 
returned.     Same  case  as  figure  185. 


and  a  tingling  and  numbness  along  the  distribution  of  the  nerve. 
These  symptoms  may  pass  away  quickly  or  the  tingling  may 
remain  several  days.  If  it  remains,  a  chronic  neuritis  is  es- 
tablished associated  with  shooting  and  neuralgic  pains.  If 
the  contusion  is  severe,  there  will  be  complete  anesthesia  and 
complete  paralysis  of  the  nerve  below  the  place  involved.  This 
may  pass  away  early  or  it  may  remain  several  months  or  it 
may  become  permanent.  Pressure  upon  the  nerve  from  callus, 
cicatricial  tissue,  and  bony  fragments  will  give  signs  of  disturbed 
sensation  and  motion  in  the  parts  supplied  by  the  nerve. 

Compression  of  the   Musculospiral  Nerve:  The  musculospiral 
nerve  supplies  the  triceps,  brachialis  anticus,  supinator  longus, 


--^    / 


-r 


Loose  fragment  ot 

I         shaft. 


-  Condyle  of  humerus^ 


Fig.  185.— Same  as  figure  186.     Lateral  view  to  show  displacement  of  fragment  (X-ray 

tracing). 


—  J —    Upper  fragment  of 
,'  humerus. 


/ 


j —  —  Middle  loose  fragment. 


I 
1-. Lower  fragment. 


/ 

Fig.  186.— Double  fracture  of  the  humerus.  Paralysis  of  the  musculospiral  nerve.  Im- 
mediate union  of  bone.  Suture  of  nerve  found  caught  between  fragments.  Gradual  recovery. 
Same  as  figure  185  (X-ray  tracing).  ^ 

166 


FRACTURES    OF    THE    ELBOW  1 6 7 

and  extensor  carpi  radialis  longior  muscles.  Inability  to  extend 
the  fingers  and  wrist  and  loss  of  supination  are  the  usual  signs 
of  motor  paralysis  following  compression  of  this  nerve.  As 
for  sensation,  there  will  be  complete  loss  or  impaired  sensation 
in  the  lower  half  of  the  outer  and  anterior  aspect  of  the  arm  and 
in  the  middle  of  the  back  of  the  forearm  as  far  as  the  wrist. 

Treatment.— Immediate  paralysis  does  not  necessarily  mean 
pressure  by  a  bony  fragment.  Such  paralysis  may  be  associated 
with  contusion;  therefore,  operative  interference  should  be 
delayed.  If  the  symptoms  persist  for  four  or  five  months,  ex- 
posure of  the  nerve  and  relieving,  if  possible,  the  conditions 
found  are  indicated.  It  is  wise  to  allow  the  fractured  bone  to 
unite  before  operating. 

The  prognosis  after  the  removal  of  pressure  and  following 
resection  and  suture  of  the  musculospiral  nerve  is  good  as  to 
the  ultimate  partial  or  complete  recovery.  After  a  few  days 
or  weeks  sensation  will  return.  After  a  few  months — five  or 
eight — motion  will  begin  to  return  (see  Figs.  184,  185,  186). 

Malignant  Disease. — Carcinoma  is  said  to  have  occurred 
secondarily  in  a  fractured  bone.  Sarcoma  develops  in  the  callus 
of  fractures.  It  is  highly  probable  that  in  many  of  the  so-called 
sarcomata  of  callus  the  disease  preexisted  in  the  bone,  and  was 
the  reason  for  the  fracture  occurring  after  trivial  injury. 


FRACTURES  OF  THE  ELBOW 

Fractures  of  the  lower  end  of  the  humerus  near  to  and  involving 
the  elbow-joint  are  frequent  in  childhood,  but  much  less  fre- 
quent in  adults.  A  familiarity  with  the  bony  landmarks  of 
the  elbow  is  essential  to  an  accurate  diagnosis.  The  more  nearly 
accurate  the  diagnosis,  the  more  efficient  will  be  the  treatment 
and  the  more  intelligent  will  be  the  prognosis.  Every  elbow 
injury,  no  matter  how  trivial,  should  be  examined  under  anes- 
thesia. 

Method  of  Examination. — The  normal  anatomical  relations 
of  the  uninjured  elbow  are  to  be  first  determined.  The  large 
prominent  internal  condyle  of  the  humerus,  the  olecranon  pro- 
cess of  the  ulna,  the  external  condyle,  the  head  of  the  radius,  are 


1 68 


FRACTl'RKS    oK    TIIIv    IlfMIvKl'S 


each  ill  turn  to  be  grasped  1)\  the'  lliunib  and  forefinger.  If  these 
bon\-  points  can  be  recognized  ii])()n  the  injured  ell)o\v,  then  a 
fracture  ought  not  to  be  overlooked. 

The  Three  Bonv  Points  of  the  Elbow  Region:  With  a  ])encil 
or  ink  the  internal  and  external  condyles  of  the  humerus  and 
the  tip  of  the  olecranon  should  be  marked,  the  forearm  being 
extended.  Normally,  these  three  points  will  be  found  to  be 
in  nearly  a  straight  line  transverse  to  the  long  axis  of  the  limb. 
The  tip  of  the  olecranon  is  a  trillc  above  this  line  (see  Figs.  187, 
188). 

Palpation  of  the  Three  Bony   Points:  Grasping  the  left  wrist 


Fig.  1S7. — The  relations  of  the  three  bony  points  at  the  elbow  in  extension  and  in  flexion 
( from  behind  1.     The  marks  are  placed  upon  the  internal  and  external  condyles  and  olecranon 

process  (diagram).  ' 


with  the  left  hand,  place  the  right  thumb  upon  the  external 
condyle,  the  third  finger  on  the  internal  condyle,  and  the  fore- 
finger on  the  olecranon.  When  the  elbow  is  at  a  right  angle, 
these  three  points  will  be  found  in  the  same  plane  with  the  back 
of  the  upper  arm.  A  similar  examination  may  be  made  of  the 
right  elbow,  changing  hands  for  convenience  (see  Figs.  1S7,  189). 
The  Head  of  the  Radius  (see  Fig.  192):  Grasping  the  elbow 
with  one  hand,  the  thumb  resting  one-half  an  inch  below  the 
external  condyle  upon  the  head  of  the  radius,  and  holding  the 
wrist  in  the  other  hand,   the  patient's  forearm  is  pronated  and 


EXAMINATKJN    OF    Tllli    IvIJJOW 


169 


supinated.  If  the  shaft  of  the  radius  is  unbroken,  the  head  of 
the  radius  will  be  felt  to  move  under  the  thumb. 

The  Carrying  Angle  (see  Figs.  190,  191):  The  lateral  angle 
that  the  supinated  forearm  makes  with  the  upper  arm  is  called 
the  carrying  angle.  It  is  important  to  remember  that  this 
angle  varies  normally  within  very  wide  limits.  Some  individuals 
have  no  carrying  angle.  Its  presence  or  absence  is  of  little 
functional  value. 

Movements  at  the   Elbow-joint :  The  movements  of  the  joint 


j^^WI 

^ 

^       ^h 

iB . 

m 

^^r 

-f  i&^-li 

■ 

»%.  ^ 

^ 

1 

^  . 

^S^'f 

M 

.^  ^M 

wT 

-I'fll 

fc^                         Jg^l^^r\ 

1 

iam 

K 

1 

ii 

Fig.  18S. — Normal  elbow.     Relation  of  the  three  bony  points  in  almost  complete  e.xtension  of 
forearm.     Prominence  of  olecranon  and  two  condyles  evident. 


should  be  determined  both  in  flexion  and  extension.  There  is 
normallv  no  lateral  motion  in  the  extended  elbow-joint.  Ab- 
normal lateral  motion  in  either  adduction  or  abduction  should 
be  detected  if  present. 

Measurements:  The  distance  between  the  two  condyles  should 
be  measured  on  the  uninjured  arm.  The  distance  from  the 
acromial  process  to  the  external  condyle  of  the  humerus  should 
also  be  measured  (see  Fig.  145). 

Having  then  established  a  standard  of  comparison  in  the 
normal  elbow,  the  injured  elbow  should  be  examined  with  the 


).— Normal  elbow.     Examination.     The  three  bony  points.     Note  position  of  tlie 
thumb  and  two  fingers  of  the  examining  hand. 


Fig.  190.— Normal  elbows.     Well-marked  carrying  angle  apparent. 
170  , 


EXAMINATION    OF    Tllli    BLHOW 


171 


greatest  care.  Even  when  there  is  great  swelhng  of  the  elbow- 
region,  steady  pressure  will  enable  the  fingers  to  reach  the  con 
dyles.  In  approaching  an  injury  to  the  elbow  the  questions 
which  arise  are:  Is  there  a  dislocation?  Is  there  a  fracture? 
Are  both  dislocation  and  fracture  present?  Is  there  a  contusion 
and  a  sprain?  Is  there  a  subluxation  of  the  radial  head?  In 
the  absence  of  positive  signs  of  dislocation,  subluxation,  and 
fracture  the  lesion  is  a  sprain  or  contusion.     In  the  absence  of 


Fig.  191. — Position  of  supination,  showing  the  carrying  angle.     The  outline  shows  the  position 
of  pronation  with  disappearance  of  the  carrying  angle. 


positive  signs  of  dislocation  and  radial  subluxation  a  fracture 
will  be  present. 

Summary  of  the  Order  of  Examination  of  the  Injured  Elboiv. — 
Notice  whether  the  swelling  and  ecchymosis  are  general  or  local- 
ized. If  localized,  that  may  determine  the  seat  of  the  lesion. 
Observe  the  carrying  angle.  Palpate  the  external  and  internal 
condyles  (see  Fig.  193),  the  olecranon  process  of  the  ulna  (see 
Fig.  194),  and  the  head  of  the  radius  (see  Fig.  192).  Deter- 
mine if  crepitus  is  present.     See  if  the  head  of  the  radius  rotates. 


17- 


FRACTl'RES    OF    THE    HUMERI'S 


Xf)te  the  relations  of  the  three  bony  points,  with  the  forearm 
flexed  at  a  right  angle  and  eonipletely  extended  (see  Figs.  1S7, 
188,  189).  Xote  anv  lateral  motion  at  the  elbow  joint  (see 
Pig-  195)-  Determine  the  possible  movements  of  the  elbow- 
joint.     Make  measurements. 

The  traumatic  lesions  of  the  elbow  may  be  grouped,  for  sim- 
plicity and  ease  of  reference,  in  the  following  manner.      During 


Fig.  192. — Normal  elbow.      Method  of  examination.     Palpating  head  of  radius.     Spot  marks 

external  condyle. 


the  routine  examination  it  is  wise  to  have  in  mind  these  possible 
individual  lesions: 

Lesions  of  the  Radius  and  Ulna:  (a)  Dislocation  of  the  radius 
and  ulna  backward  with  or  without  fracture  of  the  coronoi-d 
process  of  the  ulna. 

(6)  Subluxation  of  the  radial  head. 

(c)   Fracture  of  the  olecranon  process  of  the  ulna. 

((/)  Fracture  of  the  neck  or  head  of  the  radius. 


Fiy;.  193. — Normal  elbow.     Method  of  examination.     Grasping  the  two  condyles  of  the 

humerus. 


Fig,  194. — Normal  elbow.     Method  of  examination.     Palpating  olecranon. 
173 


174  FRACTl'RUS    iW    THE    HUMERUS 

Lesions  of  the  Lower  Hnd  of  the  Humerus:  (e)  Fracture  of 
the  internal   ejMconchle. 

(/)   Fracture  of  the  internal  condyle. 

(g)   Fracture  of  the  external  condyle. 

(Ii)  Transverse  fracture  of  the  shaft  of  the  humerus  above 
the  condyles  (supracondyloid). 

(/)  vSeparation  of  the  lower  epiphysis  of  the  humerus. 

(k)  T-fracturc  into  the  elbow-joint. 

Syuifyfoins  of  Lesions  About  flic  Elbow-joint  with  the  Differential 


Fig.  195. — Normal  elbow.     Line  between  the  condyles.     Method  of  examining  for  supracon- 
dyloid fracture. 


Diagnosis  of  Each  Lesion. — (a)  A  Dislocation  of  the  Radius  and 
Ulna  Backward  with  or  without  Fracture  of  the  Coronoid  Pro- 
cess of  the  Ulna :  There  may  be  very  great  swelling  of  the  region 
of  the  elbow.  The  relations  between  the  three  bony  points  are 
disturbed.  The  olecranon  process  is  very  prominent  posteriorly. 
The  radial  head  is  displaced  backward.  The  two  condyles  are 
far  in  front  of  the  olecranon.  There  is  abnormal  lateral  mobility. 
The  normal  movements  of  the  joint  are  restricted.  This  in- 
jury may  be  mistaken  for  a  supracondyloid  fracture.     The  im- 


DIAGNOSIS    OF    ELBOW  JOINT    LliSIONS 


175 


portant  difference  has  been  mentioned.  A  dislocation  of  both 
bones  backward,  if  reduced,  does  not  ordinarily  tend  again  to 
become  displaced;  if  it  does,  there  is  most  likely  a  fracture  of 
the  coronoid  process  of  the  ulna. 


Fig.  196. — Lower  end  of  humerus,  ante- 
rior surface.  Note  lines  of  fracture  of  in- 
ternal epicondyle  and  of  fracture  of  exter- 
nal condyle. 


Fig.  197. — Lower  end  of  humerus,  ante- 
rior surface.  Note  lines  of  supracondyloid 
fracture  and  of  fracture  of  internal  condyle. 


Fig.  198. — Lower  end  of  humerus,  anterior 
surface.     Note  lines  of  T-fracture. 


Fig.  199. — Lower  end  of  humerus,  pos- 
terior surface.  Note  olecranon  fossa  and 
trochlear  surface  for  ulna.  Note  projec- 
tion of  internal  condyle. 


(6)  Subluxation  of  the  Head  of  the  Radius:  This  takes  place 
in  children  under  five  years  of  age.  It  is  due  to  sudden  traction 
upon  the  extended  forearm,  which  so  often  occurs  in  lifting  a 
child  by  the  arm  over  a  curbstone.     The  child  presents  the  arm 


176 


FRACTIRES    OK    THK    Ill'.MP:RrS 


hanging  slightly  a\va\'  fnmi  Ihe  side,  willi  llif  c11j()\v  a  little 
flexed  and  the  hand  scmipronated.  Attempts  to  use  the  arm 
cause  pain.  The  extremes  of  flexion  and  extension  and  supina- 
tion are  painful.  Inspection  will  detect  a  slight  swelling  one- 
half  of  an  inch  to  an  inch  IdcIow  the  external  condyle  of  the 
humerus.     Tenderness   is  present   over  the  head   of   the   radius. 


Fig.  200. — Fracture  of  the  internal  condyle.     Recovery  with  "  jfunstock  "  deformity,  due  Ir 
slipping  upward  of  fragment  and  addiiclioii  of  forearm. 


The  relation  of  the  three  bony  prominences  is  preserved.  The 
details  of  this  not  uncommon  lesion  are  mentioned  because  it  is 
sometimes  mistaken  for  a  fracture  of  the  radial  head  or  a  simple 
sprain  of  the  elbow.  A  fracture  of  the  radius  below  the  neck 
has  also  been  mistaken  for  this  subluxation  of  the  head.  Careful 
detailed  examination  will  alone  clear  up  any  doubts. 

(c)    Fracture   of   the    Olecranon    Process:   The   details   of   this 


DIAGNOSIS    OF    ElvBOW  JOINT    LKSIONS 


177 


fracture  are  considered  elsewhere.     Crepitus  and  mobility  of  the 
olecranon   fragment   will    be   felt.     There   may   or   may   not    be 


Capitellum. j ^^ 

Radius. \ 


-\ Internal  condyle. 

\ 
\ 


Fig.  201. — Normal  right  arm  of  patient  in  figure  200  (X-ray  tracing). 


Internal  condyle. 


-t External  condyle. 

.._ Capitellum. 

Radius. 


Fig.  202. — Fracture  of   internal   condyle  of  left   humerus.      Recovery  with  deformity.      See 
figure  200  (X-ray  tracing). 


separation  of  the  fragments.  If  there  is  a  separation,  it  will 
be  detected  and  the  three  bony  points  will  have  their  normal 
relations  disturbed. 


178  1-KACTURKS    OF    TIIH    Iir.MIiKUS 

((/)  rVaclurc  oi'  ihc  Xcck  or  Head  of  the  Radius:  This  is  un- 
common. vSwelHng  over  the  radial  head  and  neck  is  present. 
Supination  and  pronation  are  painful  and  limited  and  attended 
by  crepitus,  muscular  spasm,  and  possibly  a  loss  of  rotation  of 
the  radial  head. 

(e)  Fracture  of  the  Internal  Epicondyle:  The  epiphysis  of 
this  epicondyle  unites  to  the  shaft  of  the  humerus  between  the 
eighteenth  and  twentieth  years.  This  fracture  is  quite  common 
among  little  children.  If  this  fracture  presents  a  small  frag- 
ment, it  is  of  little  consequence.  If  a  large  fragment  is  broken 
off,  it  is  of  consequence.  The  displacement  is  downward  and 
forward.  The  ulnar  nerve  is  sometimes,  though  rarely,  im- 
plicated  in    this   injury. 

(/)  Fracture  of  the  Internal  Condyle:  vSwelling  over  this  con- 
dvle  is  marked.  By  grasping  the  condyle  abnormal  mobility 
and  crepitus  are  detected  between  the  fragment  and  the  shaft. 
The  inner  of  the  three  bony  points  is  displaced  upward.  Lateral 
mobilitv  of  the  elbow  is  present;  adduction  is  especially  free. 
The  carrving  angle  will  be  diminished  if  there  is  displacement 
of  the  condyle  upward  (see  Figs.  200,  201,  202). 

(g)  Fracture  of  the  External  Condyle  (see  Fig.  205):  Swelling 
over  this  condyle  is  marked.  Crepitus  and  abnormal  mobility 
are  present.  The  normal  relations  of  the  three  bony  points 
arc  disturbed.  The  external  condyle  is  displaced  upward. 
The  relation  of  the  external  condyle  and  the  head  of  the  radius 
is  undisturbed.  Lateral  motion  at  the  elbow  is  or  is  not  present. 
The  transverse  measurement  of  the  elbow  is  greatest  on  the 
injured  side.     Supination  will  be  somewhat  limited. 

(li)  Transverse  Fracture  of  the  Shaft  of  the  Humerus  Above 
the  Condvles.  Supracondyloid  Fracture  (see  Fig.  206) :  The 
line  of  this  fracture  is  higher  up  on  the  shaft  than  the  line  of 
the  epiphysis.  A  fullness  will  be  noticed  in  front  of  the  elbow- 
joint,  and  posteriorly  the  point  of  the  elbow  will  appear  prom- 
inent. The  small  lower  fragment  is  displaced  backward  with 
the  bones  of  the  forearm ;  the  upper  fragment  or  shaft  of  the 
humerus  is  displaced  forward,  causing  the  fullness  in  the  bend 
of  the  elbow  (see  Fig.  208).  The  three  bony  points  maintain 
their  normal  relations.     This  distinguishes  the  fracture  from  a 


DIFFERENTIAL    DIAGNOSIS 


179 


dislocation  of  both  bones  backward  (see  Fig.  209).  Crepitus 
will  be  detected  upon  grasping  the  arm  firmly  above  and  below 
the  elbow-joint  (see  Fig.  195).  Recurrence  of  the  displace- 
ment often  follows  its  correction  unless  the  fracture  is  properly 
immobilized.  Abnormal  lateral  and  anteroposterior  mobility 
above  the  elbow- joint  is  found  (see  Figs.  206,  207). 

(i)  Separation  of  the  Lower  Epiphysis  of  the  Humerus:  The 
lower  epiphysis  of  the  humerus  unites  to  the  shaft  about  the 
seventeenth  year.  It  includes  only  the  very  lowest  end  of  the 
humerus.     The    lower    epiphysis    of    the    humerus    is    made    up 


Fig.  203. — Fracture  of  the  internal  condyle  ;  displacement  upward  of  fragment ;  union  in  dis- 
placed position — consequent  permanent  adduction  of  forearm  (after  Helferich). 


of  the  external  epicondyle,  the  capitellum,  and  the  trochlea. 
These  separate  centers  of  ossification  unite  about  the  thirteenth 
year,  and  at  about  the  seventeenth  year  they  join  the  shaft  of 
the  bone.  The  epiphysis  of  the  internal  epicondyle  is  entirely 
separate  from  the  large,  general,  lower  humeral  epiphysis.  It 
is  therefore  possible  to  have  a  complete  separation  only  after 
the  thirteenth  year. 

(j)  Injury  to  the  Lower  Epiphysis  of  the  Humerus :  This  is  a 
not  uncommon  accident.  It  occurs  usually  in  children  under  ten 
years  old.     There  is  no  change  in  the  relations  of  the  three  bon}^ 


I  So 


FRACTURES    OF    THE    HUMERUS 


points.  It  somewhat  resembles  transverse  fracture  above  the 
condvlcs.  The  diagnosis  is  made  upon  the  following  points:  The 
age  of  the  individual ;  the  history  of  the  accident ;  the  existence  of 
abnormal  mobility  at  a  ^"ery  low  level  on  the  humeral  shaft ; 
anteroposterior  mobility  very  marked,  lateral  mobility  being  less 
marked;  munied  crepitus  (this  term  is  very  suggestive,  and  is 
used  bv  Poland).  The  breadth  of  the  lower  end  of  the  humeral 
fragment  is  broader  than  in  the  case  of  a  fracture  (see  Figs.  210  to 
217  inclusive).  In  old  injuries  of  this  kind  there  is  usually  dis- 
covered a  very  considerable  thickening  of  the  lower  end  of  the 


Fig.  204.— Fracture  of  the  external  condyle  ;  union  with  fragment  displaced  upward,  resulting 
in  permanent  abduction  of  forearm  (after  Helferichj. 


humeral  shaft.     This  is  due  to  the  deposit  of  new  bone  through- 
out the  area  of  denuded  periosteum. 

(k)  T-fracture  into  the  Elbow- joint  (see  Figs.  218,  219):  The 
traumatism  which  causes  this  injury  may  be  extremely  slight. 
If  the  two  condyles  are  grasped,  crepitus  and  abnormal  mobility 
will  be  detected.  The  relations  of  the  three  bony  points  will  be 
disturbed,  according  as  one  or  both  condyles  are  displaced.  The 
transverse  measurement  of  the  condyles  will  be  found  to  be  in- 
creased. There  will  be  abnormal  lateral  mobility,  both  in  ad- 
duction and  abduction. 


DIFFERENTIAL    DIA(-;N()SIS 


i8i 


A  systematic  anatomical  examination  of  injuries  to  the  elbow 
under  an  anesthetic   will  overcome  much  of  the  indefiniteness 


^M 1 External  condyle. 

I  — ) — i Capitelluni. 

1 I'pper  radial  epiphysis. 


Fig.  205.— Fracture  of  external  condyle  of  humerus.     Child  five  years  of  age.     Nucleus  for 
capitellum  seen  below  fragment. 


Fig.  206. — Case  of  transverse  fracture  above  the  condyles  of  the  left  humerus  ;  characteristic 
deformity.     The  anterior  deformity  is  higher  than  in  a  case  of  dislocation  of  the  elbow. 


that  surrounds  these  injuries.  A  crushed  elbow,  feeling  to  the 
examining  hand  like  a  bag  of  bones,  can  not  always  be  accurately 
diagnosed,  some  of  the  details  of  the  lesions  naturally  remain- 


IS2 


FRACTURES    OF    THE    Hl'MERlS 


ing  undetermined.  The  Rchitgen  ray  in  these  doubtful  cases 
win  be  of  material  assistance.  The  importance,  however,  of 
making  such  a  careful  eliminative  examination  as  is  described, 
both  from  the  point  of  view  of  treatment  and  prognosis,  can  not 
be  overestimated. 

Treatment. — The  object  of  treatment  is  to  restore  the  elbow- 
joint  to  its  normal  condition.  If  the  fracture  is  attended  by 
great  swelling,   it  will  be  necessary  to  temporarily  support  the 


Fig.  207. — Transverse  fracture  abo\e  the  condyles  of  tlie  humerus.     Same  as  figure  206. 


arm  until  the  sw^elling  reaches  its  maximum  and  begins  to  sub- 
side. The  right-angle  internal  angular  splint  is  the  most  satis- 
factory for  this  purpose  (see  Figs.  220,  221).  The  maximum 
swelling  will  have  taken  place  after  fortv-eight  to  seventv-two 
hours.  This  temporary  dressing  will  rarely  be  needed.  In 
general,  it  may  be  stated  that  the  arm  should  be  placed  in  that 
position  in  which  it  is  found,  upon  experiment  with  the  fracture 
under  consideration,  that  the  fragments  are  best  held  reduced. 
Fractures  of  the  internal  epicondyle,   of  the  internal  condyle,  of 


TREATMENT    OF    FRACTURES    OF    TllE    ElvBOW 


'«3 


the  external  condyle,  and  '[-fractures  into  the  joint  are  best  treated, 
as  a  rule,  in  the  acutely  flexed  position. 

Experimental   evidence,    both   upon   the   cadaver   and   on   the 


Fig.  208. — Supracondyloid  fracture  of 
humerus.  Elbow  flexed  to  a  right  angle. 
Diagram  to  show  displacement  of  bones. 


Fig.  209.— Dislocation  of  both  bones  of 
the  forearm  backward.  Elbow  flexed  to 
right  angle.  Diagram  showing  relative 
position  of  bones.  Compare  with  figure 
208. 


Humeral  shaft,  v. 


Epiphysis. 

Capitellum. 


Fig.  210. — Displacement   of    lower  epiphysis  of    humerus   backward,   with   fracture  of    the 
diaphysis.     Child  seven  years  of  age  (X-ray  tracing). 


anesthetized  living  subject,  confirmed  by  clinical  experience 
extending  over  a  number  of  years  in  the  hospital  and  private 
practice    of    many    different    surgeons,    demonstrates    that    the 


Shaft  of  humerus. 

Capitelluni 


Radius. 


—  Periosteum. 


'     _  Lower  epiphysis  of 

.  humerus. 


•  Uhiar  shaft. 


Fig.  211. — Separation  of  the  lower  epiphysis  of  the  humerus  and  displacement  of  the  fore- 
.-irm  inward.  Boy  nine  years  of  age.  See  figure  212  (X-ray  tracing)  (Massachusetts  Genera- 
Hospital,  1502). 


Epiphysis. 1- 


Capitelluni. ^ 


Epiphysis. 

Shaft  of  humerus. 
Ulna. 


Fig.  212.— Lateral  view  of  figure  211,  showing  forward  displacement  of  the  shell  of  the 
epiphysis  and  the  lateral  displacement  of  the  ulna  (X-ray  tracing)  (Massachusetts  General 
Hospital,  1502). 


TREATMENT    OF    FRACTURES    OF    THE    EUBOW 


185 


acutely  flexed  position  actively  reduces  and  holds  reduced  the 
fractures  previously  mentioned.     In  the  acutely  flexed  position 


Detached 
periosteum.  V 


Capitellum 


Humerus. 


Fig.  213.— Same  as  figure  211,  after  reduction.     Lateral  view.     Internal  right-angle  splint  seen 
in  position  (X-ray  tracing). 


Shaft  of  humerus. 


Epiphysis. 


Fig.  214. — Separation  of  the  lower  humeral  epiphysis  (X-ray  tracing)  (Massachusetts  General 

Hospital,  742). 


the  coronoid  process  in  front,  the  trochlear  surface  of  the  olec- 
ranon behind,  and  the  fasciae  posteriorly  and  laterally,  together 


iS6 


KRACTl'RES    oK    THE    Hl'MERl'S 


with    the   Iciulon  of  the   triceps  posteriorly,    hold    the   fragments 
reduced  and  close  to  the  shaft  of  the  humerus. 


—Shaft  of  humerus. 

l Lower  humeral  epipliysisaiul 

.  bits  from  the  diaphysis. 

—  T CapiteHuui. 


Fig.  215. — Separation  of  the  lower  humeral  epiphysis.  Child  nine  years  of  age.  Separation 
reduced.  Capitellum  and  epiphysis  distinctly  seen  in  the  lateral  view.  Internal  angular  tin 
splint  shown. 


Olecranon  fossa. 

Internal  portion  of, 
epiphysis. 


Ulna 


Humeral  epiphysis  and 

—  bits  from  the  diaphy- 
sis. 

■  Caijitellum. 
-—  -  Radial  epiphysis. 

—  Radius. 


Fig.  216. — Separation  of  the  lower  epiphysis  of  the  humerus,  after  union.  Anteroposterior 
view.  This  figure  illustrates  the  fact  that  the  epiphysis  does  not  include  the  condyles  of  the 
humerus  (X-ray  tracing;. 


Method  of  Using  the  Acutely  Flexed   Position:  The  condyles 
of  the  humerus  are  grasped  by  the  thumb  and  finger  of  one  hand. 


TREATMENT    OF    FRACTURES    OF    TIIE    ELHOW 


187 


a  finger  of  the  other  hand  is  placed  in  the  bend  of  the  elbow, 
traction  is  made  upon  the  forearm,  and  it  is  slowly  flexed  to  an 
acute  angle.     While  the  forearm   is  being   flexed,   traction   and 


-United  huiiieral 

epiphysis. 
■Capitellum. 


Radial  epiphysis. 

Fig-.  217. — Separation  of  the  lower  humeral  epiphysis,  after  union.     Lateral  view.     Extension 
normal.     Flexion  to  a  right  angle  (X-ray  tracing)  (Massachusetts  General  Hospital,  1556). 


Fig.  218. — T-fracture  of  elbow.  Man  of 
forty-five,  fell  twenty  feet  and  struck  elbow, 
producing  compound  fracture.  Arm  am- 
putated (Warren  Museum,  specimen  999). 


Fig.  2ig. — T-fracture  of  humerus,  low 
down.  Man  of  forty-eight,  fell  downstairs. 
Arm  amputated  (Warren  Museum,  speci- 
men 1 102). 


lateral  pressure  are  brought  to  bear  upon  the  loose  fragments 
of  the  humerus  to  correct  existing  malpositions.     These  manip- 
ulations will  materially  assist  in  the  reduction    (see   Fig.    222). 
The  degree  of  flexion  will  be  determined  by  the  obstruction 


i8S 


KRACTrRKS    OF    THE    HUMERITS 


offered  by  the  local  swelling.  If  the  swelling  is  great,  or  is  likely 
to  increase  very  much,  then  the  degree  of  flexion  must  be  less 
than  when  there  is  no  swelling.  In  the  bend  of  the  elbow,  to 
prevent  chafing,  is  placed  a  piece  of  gauze  upon  which  has  been 
dusted  a  dry  powder.  This  acutely  flexed  position  is  maintained 
by  an  adhesive-plaster  strap,   three  inches  wide,   passing  about 


Fig.  220. — Method  of  manufacture  of  tin  internal  right-angle  splint :  a,  Form  into  which 
piece  of  tin  is  folded  (with  vise  and  hammer)  ;  b  shows  tlie  bend  in  the  back  ridge  completed 
(bent  with  pliers,  hammered  close  in  the  vise) ;  c,  the  completed  splint  with  edges  shaped  and 
covered  with  adhesive  plaster,  and  with  the  surfaces  of  the  splint  properly  concaved. 


Fig.  221. —  Patterns  of  pieces  used  in  making  the  usual  (soldered)  internal  right-angle  splint, 
seen  applied  in  figure  231. 


the  arm  and  forearm  (see  Fig.  223).  This  strap  should  be  placed 
upon  the  upper  arm  as  high  as  the  axillary  fold,  and  upon  the 
forearm  just  above  the  styloid  of  the  ulna.  A  piece  of  linen  or 
compress  cloth  (cotton  cloth)  is  placed  under  the  forearm  and 
hand  where  they  would  come  in  contact  with  the  skin  of  the 
chest.     This  should  be  pinned  so  as  not  to  slip  from  position.     The 


TREATMENT    OP    FRACTURES    OF    THE    ElJiOW  1 89 

arm  thus  flexed  is  supported  by  a  swathe  sHng  (see  Fig.  224J 
made  of  cotton  cloth,  fifteen  inches  wide,  folded  three  times, 
and  long  enough  to  extend  twice  around  the  body.  This  is 
applied  as  illustrated  (see  Figs.  224,  225,  226).  The  elbow  is 
held  to  the  side  by  pinning  a  strip  of  compress  to  the  swathe 
at  the  elbow  and  posteriorly   (see   Fig.    225). 

Precautions  in  Using  the  Acutely  Flexed  Position:  The  arm 
is  inspected  each  day  for  the  first  week.  It  is  necessary  to  note 
whether  with  the  increase  in  the  swelling  the  flexion  of  the  arm 


Fig.  222.— Supracondyloid  fracture  of  the  humerus.  Method  of  reduction  before  applying 
retentive  splint.  Countertraction  on  upper  arm.  Traction  on  condyles  of  humerus  with  right 
hand  ;  backward  pressure  with  thumb  of  left  hand.  Also  illustrative  of  method  of  beginning 
acute  flexion. 


should  be  diminished,  and  whether  with  diminution  in  the  swell- 
ing flexion  may  be  increased  with  safety.  The  radial  pulse 
should  be  felt  as  the  flexion  is  diminished,  so  as  to  avoid  com- 
pression of  the  vessels  at  the  bend  of  the  elbow.  There  should 
be  no  pain  associated  with  this  acutely  flexed  position.  A 
certain  amount  of  discomfort  may  be  complained  of.  Real 
pain  will  be  indicative  of  too  great  pressure,  and  if  it  is  present, 
the  forearm  should  be  less  acutely  flexed.  Chafing  should  be 
looked  for  at  the  bend  of  the  elbow,  under  the  forearm  and  hand 


igo 


FRACTl^RES    OF    THIv    IH'MERl'S 


and  on  the  chest,  where,  if  necessary,  fresh  powder  and  com- 
press cloth  should  be  placed.  The  edge  of  the  adhesive  plaster 
may  cause  chafing  of  the  skin  upon  the  posterior  surface  of  the 
forearm  and  upper  arm.  It  may  be  necessary  to  place  beneath 
the  plaster  small,  carefulh'  folded  compresses  of  cotton  cloth  to 
protect  the  skin  (see  Fig.  224). 

Later,  in  changing  the  adhesive  plaster,  the  skin  may  be  washed 


^ 

M  ' 

^^V*'-,v 

V   «       '■' 

1 

T  j 

1 

Fii;.  223. — Left  elbow  in  position  of  forced  fie.xion.  Gauze  in  bend  of  elbow.  Thin  axillary 
pad.  Pad  under  hand  and  wrist.  Gauze  protection  under  forearm,  held  by  safety-pin  from 
slipping.  Adhesive  plaster  maintaining  fie.xion.  Skin  protected  on  ujjper  arm  by  .t^auze  coni- 
jiress  from  cutting  of  adhesive  plaster. 


with  alcohol  and  then  with  soap  and  water,  to  the  great  comfort 
of  the  patient.  The  alcohol  removes  all  adhesive  plaster  sticking 
to  the  skin.  If  the  adhesive  plaster  chafes  the  skin,  as  it  so 
often  does  in  children,  it  will  be  necessary  to  place  a  bit  of  gauze 
under  the  adhesive-plaster  strips,  leaving  enough  of  the  sticky 
side  of  the  plaster  uncovered  to  catch  the  skin  and  thus  keep 
it  from  slipping  entirely  loose.     The  carrying  angle  of  the  arm 


TREATMENT    OF    FRACTURES   OF    THE    ELBOW 


191 


will  be  preserved  if  the  fragments  are  approximately  reduced; 
it  can  not  be  maintained  otherwise.  The  acutely  flexed  position 
reduces  the  fragments  in  the  fractures  under  consideration ; 
therefore  it  will  preserve  the  carrying  angle. 

Transverse  Fracture  of  the  Shaft  above  the  Condyles. — There  is 
usually   an   overlapping   of   the   fragments.     This   is   evident   in 


Fig.   224. — Applj'ing    figure-of-eight    cravat   to    flexed   elbow 
(after  Lund). 


Fig.  225. — Strap  from 
elbow  to  cravat  to  prevent 
abduction  of  flexed  elbow. 


the  backward  displacement  of  the  lower  fragment  and  forearm 
and  in  the  forward  displacement  of  the  upper  fragment. 

It  will  be  necessary  in  order  to  effect  reduction  of  this  fracture 
to  make,  with  the  aid  of  an  assistant,  countertraction  and  pres- 
sure backward  upon  the  upper  fragment  while  traction  and  a 
forward  pull  are  made  upon  the  lower  fragment  by  grasping  the 
arm  above  the  condyles  (see  Fig.  222).  The  internal  right- 
angle  splint  will  best  hold  this  fracture,  for  it  exerts  continuous 


19: 


FRACTURES    OF    THE    HUMERUS 


pressure  l^ackward  u})()n  the  upper  fragment  and  prevents  dis- 
placement (see  Figs.  228,  229).  It  is  padded  with  sheet  wadding 
and  applied  as  illustrated.  Two  straps  are  needed  upon  the 
forearm  to  hold  this  splint  in  good  position  (see  Figs.  230,  231). 
The  strap  at  the  wrist  should  be  so  applied  that  there  is  no  pres- 
sure   upon    the    styloid    process    of    the    ulna.      Long-continued 


Fig.  226. — Fastening  figure-of-eight  cravat  over  folded 
compression  on  opposite  side  of  chest.  Elbow  region  open  to 
inspection. 


Fig.  227. — Adhesive 
plaster  strip  showing 
bits  of  gauze  arranged 
so  as  to  protect  skin 
from  plaster  without 
impairing  efficiency  of 
the  plaster. 


pressure  upon  this  bony  process  would  cause  a  pressure  sore. 
In  applying  the  adhesive  plaster  it  is  wise  to  apply  it  so  loosely 
that  there  is  no  undue  pressure  upon  the  arm,  which  might 
retard  the  circulation.  The  arm  is  then  covered  with  a  roller 
bandage  of  sheet  wadding,  over  which  is  placed  a  roller  bandage 
of  cheese-cloth.     This   should   be   applied   smoothly   and   firmly 


TREATMENT    OF    FRACTURICS    OI*    Till'     EUiOW 


'93 


from  the  hand  to  the  upper  end  of  the  sphnl.  As  the  swelling 
about  the  elbow  begins  to  subside,  pads  of  cotton  cloth  (com- 
press cloth)  may  be  placed  at  each  side  of  the  olecranon  below 
each  condyle.  The  pressure  of  a  frequently  renewed  bandage 
on  these  pads  will  hasten  the  disappearance  of  the  swelling. 
It  is  important  to  avoid  the  forward  and  backward  deformity 
in  treating  this  fracture  (see  Figs.  232,   233,   234). 

Dislocation  of  Both  Bones  of  the  Forearm  Backward. — If  there 


Fig.  22S.— Fracture  of  the  elbow.  Application  of  the  inteniai  right-angle  splint.  First 
strap  already  applied.  Manner  of  holding  splint  and  arm  as  the  forearm  is  flexed  up  to  the 
splint  (see  Fig.  229). 


is  no  tendency  to  displacement  after  reduction  is  accomplished, 
the  right-angle  position  with  internal  splint  is  the  best  treat- 
ment. If,  on  the  other  hand,  there  is  a  tendency  to  displace- 
ment, the  acutely  flexed  position  will  be  the  best  for  the  arm 
because  in  case  the  coronoid  process  is  broken  it  will  insure 
its  close  approximation  to  the  ulna. 

Separation  of  the  lower  epiphysis  of  the  humerus  will  be  best 
treated  in  the  right-angle  position,  the  same  as  a  fracture  of  the 
humerus  above  the  condyles  (see'  Figs.  213,  215,  235). 
13 


[94 


FRACTfRKS    nl*    TUT-:    IirMI-:RrS 


J-'iachtic  of  till-  inck  oj  Uic  ratlins  is  best  treated  1)\-  tlie  intern-al 
right-angle  splint. 

l-'ractitrc  oj  the  olicrcauui  is  discussed  elsewhere. 


Fig.  22q. — Fracture  of  the  elbow.     Application  of  the  internal  angular  splint.     Placing  second 
strap.     The  angle  of  the  splint  is  crowded  into  the  bend  of  the  elbow  (see  Fig.  228). 


Fig.  230. — Two  straps  insufficient  to  hold        Fig.  231. — Third   strap  is  necessary  to  hold 
elbow  in  internal  right-angle  splint.     Splint  the  splint  close  to  the  flexed  elbow, 

has  slipped  away  from  the  bend  of  the  elbow. 


The  After-care  of  Injuries  to  the  Elbow. — The  reapplying 
of  splints  and  of  apparatus  should  be  done  often  enough  to  be 


THE    AFTER-CARE   OF    INJURIES    TO    THE    EUJOW 


195 


sure  that  they  are  efficient,  and  that  there  is  no  undue  swelHng 
or  pressure  upon  the  arm.  Rebandaging  the  hand  and  the  arm 
each  day,  if  the  internal  angular  splint  is  used,  is  important. 
All  apparatus  should  be  removed  at  least  once  a  week,  and 
carefully  inspected  twice  during  this  interval.      Passive  motion 


Fig.  232. — Supracoiidyloid  fracture.  Ob- 
liquity of  the  line  of  fracture  from  behind 
downward  and  forward.  Diagram  show- 
ing anterior  deformity  with  elbow  flexed. 


Fig.  233. — Supracondyloid  fracture.  Ob- 
liquity of  the  line  of  fracture  from  above 
downward  and  backward.  Diagram  show- 
ing posterior  deformity  if  acute  flexion  of 
forearm  is  attempted. 


Fig.  234. — Supracondyloid  fracture  with  slight  anterior  displacement,  wired.  Recovery, 
with  slight  anterior  bending  of  fragments.  Wire  seen  in  situ  (X-ray  tracing.  Massachusetts 
General  Hospital,  1077). 


should  be  instituted  late  rather  than  early.  In  most  instances 
it  will  be  wise  to  dela}^  passive  motion  until  union  is  firm — from 
the  fourth  to  the  sixth  week.  It  should  be  of  the  gentlest  sort; 
passive  motion  that  is  painful  does  harm. 

Massage  to  the  hand,  wrist,  forearm,  elbow,  and  upper  arm. 


196 


rkACTrKUS    oF    THE    IIl'MIiRrS 


after  Uie  ]:)rinuiry  s\vc'llin,<;  has  !)c-,i,mn  to  subsiflc,  is  of  great  value. 
It  should  be  given  at  first  without  disturbing  the  apparatus 
and  the  retentive  adhesive  plaster.  Given  every  other  day, 
it  will  accomplish  considerable  in  maintaining  tlie  integrity  of 
the  muscles  of  the  ]jart.  The  employment  of  a  professional 
masseuse  is  not  always  necessary.  The  physician  should  give 
the  massage  or  instruct  a  competent  person  how  to  give  it. 

Omission  of  Splint   or  Retentive  Apparatus:  This  should   be 
tentative  and  gradual  after  union  is  known  to  be  firm — in  the  fifth 


Fig.   235. — Separation  and  backward  displacement   of  lower  epiphysis   of   liinnerus.     Note 
stripping  of  periosteum  off  posterior  surface  of  shaft.     Right-angled  splint. 


or  sixth  week.  The  arm  should  be  allowed  to  rest  in  a  sling  with- 
out the  splint  for  an  hour  and  then  the  splint  applied.  The 
following  day  a  longer  interval  is  granted  without  the  splint. 
Gradually,  the  splint  is  removed  entirely.  A  snugly  fitting 
bandage  will  often  prove  comfortable  as  a  support  on  first  leaving 
off  the  splint.  Passive  motion,  massage,  and  active  use  of  the 
arm  will  now  assist  in  regaining  the  use  of  the  joint.  At  this 
stage  the  carrying  of  dumb-bells,  pails  or  baskets  filled  with 
sand,  and  the  doing  of  certain  gymnastic  movements  with  the 


THE    PROGNOSIS    OK    FRACTURPCS    OK    TliK    ULBOW 


197 


injured  arm  will  be  of  material  aid.  All  violent  exercise  of  the 
part  is  to  be  avoided.  That  amount  of  exercise  may  be  allowed 
that  leaves  the  arm  moderately  tired.  A  fatigue  that  is  mA 
recovered  from   within  a  half-hour's  rest  is  excessive. 

The  Prognosis. — Up  to  the  time  of  the  present  introduction 
of  the  acutely  flexed  position  in  the  treatment  of  fractures  at 
the  elbow,  the  movement  most  easily  lost  and  with  greatest 
difficulty  regained  was  that  of  flexion.     By  the  use  of  the  acutely 


Fig.  236. — Diagram  to  show  the  amount  of  the  limitation  of  extension  that  may  be  caused 
by  very  moderate  caUus  (a)  in  the  olecranon  fossa,  without  displacement  of  fragments  (median 
section  of  dry  bones). 


flexed  position  in  suitable  cases  the  prognosis  has  improved 
remarkably  in  this  respect.  Now  all  of  flexion  is  ordinarily 
preserved,  and  the  more  easily  acquired  extension  is  obtained 
as  usual,  so  that  the  prognosis  as  to  motion  in  these  cases  is 
good.  Although  anatomically  perfect  results  are  not  always 
obtained,  most  fractures  of  this  region  recover  with  a  useful  arm. 
These  fractures  of  the  elbow  region  should  be  kept  under  obser- 
vation for  at  least  four  months.     It  is  wise  to  treat  such  cases 


198  FRACTURES    OF    THE    IIIMICRUS 

unlil  all  lliat  can  bo  achieved  toward  a  restoration  of  function 
has  been  acconijjlished. 

At  the  time  of  the  first  examination  of  the  elbow  the  nature 
of  the  injury  and  its  seriousness  should  be  explained  carefully 
to  the  patient  or  his  friends.  A  guarded  outlook  should  be  ex- 
pressed, parlicularh'  with  reference  to  the  function  of  the  joint. 
Some  limitation  of  motion  may  exist  after  all  that  is  possible 
has  been  done  (see  Fig.  236).  How  much  limitation  of  motion 
will  exist  it  is  impossible  to  state.  There  may  be  none  what- 
ever. The  patient  and  his  friends  should  be  encouraged  with 
the  statement  that  just  as  great  usefulness  of  the  elbow-joint 
will  be  obtained  as  is  consistent  with  the  character  of  the  injury. 
The  importance  of  the  injury  demands  of  every  physician  a 
painstaking  anatomical  examination  with  the  aid  of  an  anesthetic, 
careful  attention  to  minute  details  in  the  initial  treatment,  and 
intelligent  solicitude  in  the  after-care  of  all  traumatisms  to  the 
elbow-joint. 


CHAPTER  X 
FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

FRACTURES  OF  BOTH  RADIUS  AND  ULNA 

The  most  common  seats  of  fracture  are  in  either  the  middle 
or  lower  thirds  of  the  bones.  The  fracture  of  the  radius  is  often 
a  little  higher  than  the  fracture  of  the  ulna  (see  Figs.  237-241 
inclusive). 

Symptoms. — The  arm  can  not  be  used  without  pain.  In  a 
muscular  or  fat  arm  with  little  separation  of  the  fragments 
there  may  be  no  deformity  excepting  the  localized  swelling 
of  the  seat  of  fracture.  Deformity  will  be  determined  by  the 
displacement  of  the  bones.  If  the  seat  of  fracture  is  not  obvious, 
the  forearm  should  be  grasped  by  the  two  hands  (see  Fig.  242) 
and  gentle  but  firm  movement  attempted,  to  determine  the  pres- 
ence of  abnormal  motion  and  crepitus.  Motion  should  be 
attempted  in  all  directions,  for  the  bones  may  be  fractured  and 
yet  be  locked  when  movement  is  made  in  one  direction  only. 

Incomplete  or  Greenstick  Fracture  of  the  Bones  of  the 
Forearm  (see  Figs.  243,  247). — This  is  a  partial  break  across 
the  bone,  with  bending  at  the  seat  of  fracture.  In  children  be- 
tween the  ages  of  two  and  fourteen  years  injury  to  the  bones 
of  the  forearm  results  usually  in  a  greenstick  fracture.  Either 
one  or  both  bones  may  be  broken.  One  bone  may  be  com- 
pletely fractured  while  the  other  is  incompletely  broken. 

Deformity  is  very  evident.  Pain  and  tenderness  at  the  seat 
of  fracture  are  present.  Crepitus  is  absent  unless  one  bone  is 
completely  fractured.  Children  having  these  fractures  are  often 
seen  a  week  or  two  after  the  injury ;  they  are  said  to  have  ' '  sprained 
the  arm"  and  "are  unable  to  use  it  well  at  the  present  time." 
Careful  inspection  will  detect  the  characteristic  bowing  at  the 
seat  of  a  greenstick  fracture.  Slight  callus  will  be  present  if  a 
little  time  has  elapsed   since  the  injury. 

199 


FRACTURE    OF    NECK    AND    HEAD    OF    RADHJS 


20I 


Fracture  of  the  Neck  and  Head  of  the  Radius. — These 
fractures  are  rarely  unassociated  with  lesions  of  the  humerus 
and  ulna.  A  fracture  of  the  external  condyle  of  the  humerus 
and  backward  dislocation  of  both  bones  of  the  forearm  have 
been  noted  with  these  fractures. 

■  Local  swelling  and  tenderness  over  the  radial  head  and  neck 
are  apparent.  The  swelling  is  greater  than  in  a  simple  sub- 
luxation of  the  radius,  and  is  limited  to  the  upper  third  of  the 
radial  side  of  the  forearm.  There  is  pronation  of  the  forearm. 
Flexion  and  extension,  in  the  absence  of  associated  lesions  such 


Fig.  238. — Fracture  of  both  bones  of  the  forearm  above  wrist.     A  not  uncommonly  overlooked 
and  frequent  injur}-  (Children's  Hospital,  P.  Brown). 


as  fracture  of  the  external  condyle  of  the  humerus,  are  possible. 
Attempted  rotation  of  the  radius, — that  is,  supination, — elicits 
pain,  muscular  spasm,  and  perhaps  crepitus.  The  head  of  the 
bone  does  not  usually  rotate  with  the  shaft,  at  least  not  as  it 
does  normally.  Subluxation  of  the  radial  head  and  fracture 
of  the  external  condvle  of  the  humerus  are  the  two  lesions  with 
which  a  fracture  of  the  radial  neck  and  head  is  most  often  con- 
fused. The  points  of  difference  have  been  indicated.  The 
X-ray  is  here  of  decided  value.  It  is  often  difficult  on  account 
of  overlying  muscle  and  swelling  of  the  soft  parts  to  palpate  the 


202       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

head  of  the  radius  with  accuracy.      Pressure  over  the  shaft  of 
the  radius  at  about  its  middle  ehcits  pain,  if  a  fracture  of  the 


Epiplnseal  line. 


Radial  fracture. 


Fliipliyseal  line. 
I'lnar  fracture. 


Fig.  239. — Fracture  of  both  bones  of  the  forearm  near  the  wrist ;  different  levels.     No  dis- 
placement in  either  place  (Massachusetts  General  Hospital,  1384.    X-ray  tracing). 


Radial  head. 


Radial  shaft. 


Greater  sigmoid  cavity 

of  the  ulna.. 


Ulna  shaft. 


Fig.  240.— Common  displacement  in  fracture  of  the  neck  of  the  radius  (after  Mouchet). 


radial  neck  be  present,  at  the  seat  of  fracture.     An  X-ray  of  the 
elbow  will  determine  a  diagnosis. 

Fracture    of   the   Shaft   of   the   Radius    (see   Figs.    250-255 


'/////, 


Fig.  241. — Fracture  of  both  bones  of  the 
forearm  at  the  middle,  showing  falling  to- 
gether of  broken  ends  (X-ray  tracing). 


Fig.  242. — Fracture  of  both  bones  of  the 
forearm,  showing  differences  in  level  and 
that  the  seat  of  fracture  is  in  the  lower 
third  of  bones. 


Fig.  243.— Fracture  of  radius  alone.  Slight  lateral,  considerable  anteroposterior,  dis- 
placement. The  fallacy  of  depending  upon  an  X-ray  taken  in  one  plane  only  is  here  illus- 
trated (X-ray  tracing). 

203 


204 


FRAC'ITKHS    OF    THE    BOXES    OF    THE    FoKIvARM 


inclusive). — This  is  usually  caused  bv  direct  violence.     The  frac- 
ture   occurring    at    anv  part    of   the    shaft   presents   no  unusual 


Fijj.  244. — Separation  of  lower  radial  epiphysis.     Note  the  dorsal  displacement  and  deform- 
ity seen  in  outline  and  that  there  is  little  lateral  displacement  (M.  G.  H.,  Dodd). 


Fijj.  245. — Note  lateral  displacement  of  separated  lower  radial  epiphysis.     Child  about  eight 
years  old   (M.G.H.,  Dodd). 


svmptoms.     The  head  of  the  bone  does  not  rotate  with  the  shaft 
unless  the  fragments  are  locked.     Abnormal  mobility,  pain,  and 


FRACTURIJb    OF"    BOTH    RADIUS    AND    ULNA 


205 


crepitus  are  present.  The  displacements  vary  with  the  situation 
of  the  fracture.  Pronation  and  supination  will  be  limited  and 
painful.  This  fracture  has  been  mistaken  for  a  subluxation  of 
the  radial  head.     A  fracture  of  the  radial  shaft  at  the  junction 


Fig.  246.— Note  dorsal  displacement  of  separated  lower  radial  epiphysis.     Child  about  eight 
years  old  (M.  G.  H.,Dodd). 


Fig.  247.— Manner  of  grasping  forearm  to  detect  the  presence  of  fracture.     Note  the  firnmess 

of  grasp. 


of  the  lower  and  middle  thirds  will  sometimes  suggest  very  plainly 
the  lateral  deformity  in  a  Colles'  fracture,  the  prominent  ulna 
and  apparently  shortened  styloid  process  of  the  radius  being 
in  evidence.     If  the  fracture  occurs  in  the  upper  third  of  the 


2o6 


FRACTIRI-S    OF    THE    BONES    OF    TIIIv    FOREARM 


bone,  the  displacement  of  the  upper  fragment  will  be  consider- 
able. 

Separation  of  the  Lower  Epiphysis  of  the  Radius. — The 
lower  radial  epiphysis  unites  to  the  shaft  of  the  bone  at  the 
twentieth  year.  Previous  to  this  age  a  separation  of  the  epiphy- 
sis is  not  at  all  uncommon.  Many  cases  of  separation  of  this 
epiphysis  are  thought  to  be  Colles'  fractures,  and  thev  are  treated 
as  such.     The  treatment  of  a  Colles'  fracture  may  present  con- 


Fig.  24S. — Greenstick  fracture  of  both 
bones  of  the  forearm.  Notice  characteris- 
tic deformity  (X-ray  tracing). 


Fig.  249. — Complete  fracture  of  uhia 
and  greenstick  fracture  of  radius  (X-ray 
tracing). 


siderable  difficulties.  Ordinarily  the  treatment  of  a  separa- 
tion of  this  epiphysis  is  simple.  There  is  little  difficulty  in  main- 
taining the  fragments  in  position  in  separation  of  the  epjiphy- 
sis.  The  epiphyseal  separation  requires  a  short  time  in  splints. 
A  soft,  cartilaginous  crepitus  is  felt.  There  are  usually  less 
swelling  and  less  pain  than  in  a  Colles'  fracture.  The  deformity 
is  quite  constant:  a  prominence  near  the  carpus  on  the  dorsum 
of  the  wrist  and  a  prominence  higher  up  on  the  palmar  surface 


Fig.  250.— Fracture  of  radius.  Slight 
lateral  dispracement.  See  figure  251  (X- 
ray  tracing). 


Fig.  251.— Fracture  of  radius.  Slight 
anteroposterior  displacement  (same  as  Fig. 
250,  X-ray  tracing). 


/W\^ 


Fig.  252.— Comminuted  fracture  of  ra- 
dius, low  down,  and  of  ulnar  styloid  (X-ray 
tracing). 


Fig.  253.— To  illustrate  so  great  damage 
to  lower  end  of  radius  that  complete  restor- 
ation to  normal  is  impossible  (X-raj-  trac- 
ing). 


207 


:5  3 


b&~    • 

i-  tn  a 

0 

=  OJ  rt 

asi 

^"3 

2o8 


FRACTURE  OF  CORONOID  PROCRSS 


209 


of  the  wrist.     There   is  ahnost  no  tendency  to   reproduction  of 
the  deformity  after  it  is  once  reduced. 

Fracture  of  the  shaft  of  the  ulna  occurs  usually  because 
of  a  direct  blow  received  upon  the  arm  raised  for  protection. 
It  is  more  uncommon  than  fracture  of  the  radius  (see  Figs.  258, 

259)- 

Localized  tenderness,  pain  upon  attempting  to  use  the  fore- 
arm, obscure  discomfort  in  the  arm  after  an  injury— these  may 
be  the  only  signs  of  fracture.     There  is  no  general  swelling  of 


Fig.  256.— Oblique  fracture  of  the  shaft  of 
the  radius. 


Fig.  257.— Old  fracture  of  both  bones 
of  the  forearm ;  pseudoarthritis  of  ulna. 
Radial  fracture  has  united  (X-ray  tracing). 


the  forearm.  Ordinarily,  there  will  be  very  Httle  displacement, 
because  the  radius  serves  as  a  splint  for  the  broken  bone.  Crepitus 
may  be  detected  if  the  ulna  is  grasped  between  the  fingers,  placed 
either  side  of  the  fracture,  and  motion  is  attempted.  The  shaft 
of  the  ulna  being  subcutaneous  throughout  its  entire  extent, 
the  tender  seat  of  fracture  can  be  easily  determined. 

Fracture  of  the  coronoid  process  of  the  ulna  is  associated 

with  backward  dislocation  of  the  ulna.     It  is  a  rare  accident. 

A  very  small  fragment  is  broken  off,  and  it  is  not  much  displaced. 

If  in  any  dislocation  of  the  forearm  backward  recurrence  of  the 

14 


2IO 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


(leformitv  after  rcduclion  occurs  readilv,  a  fracture  of  the  coro- 
noid  should  be  suspected.  This  will  be  confirmed  by  the  dis- 
covery of  a  small  hard  mass  in  front  of  the  elbow-joint  just 
above  the  insertion  of  the  brachialis  anticus  muscle;  roughly, 
a  finger-breadth  above  the  bend  of  the  elbow.  This  small  hard 
mass  mav  give  crepitus  upon  being  manipulated.  It  is  very 
diflicult   to   detect   this  fragment   of  the  coronoid   process  even 


Fig.  258. — Fracture  of  the  shaft  of  the 
uhia.  Slight  lateral  displacement.  Local- 
ized tenderness  clinically  the  only  symp- 
tom (Massachusetts  General  Hospital,  1036. 
X-ray  tracing). 


Fig.  25g. — Fracture  of  ulna,  low  down, 
with  considerable  lateral  displacement  and 
shortening  of  shaft  (X-ray  tracing.  Mas- 
sachusetts General  Hospital,  5693). 


under  the  most  favorable  conditions.  The  Rontgen  ray  may 
discover  it. 

Treatment  of  Fractures  of  the  Forearm. — The  objects 
of  treatment  are  to  prevent  permanent  deformity  and  to  pre- 
serv^e   the   movements   of   pronation   and   supination. 

Fractures  of  Both  Radius  and  Ulna. — All  fractures  of  the  fore- 
arm attended  with  overriding  or  angular  displacement  that  do 
not  vield  readily  to  traction,  countertraction,  and  pressure 
should  be  reduced  under  complete  anesthesia.  While  an  as- 
sistant makes  countertraction  upon  the  upper  part  of  the  forearm 


TREATMENT  211 

the  surgeon,  holding  the  lower  end  of  the  limb,  makes  strong, 
even  traction,  at  the  same  time  pressing  the  bones  into  jjosi- 
tion.  When  the  angular  deformity  is  corrected,  the  forearm 
should  be  strongly  supinated.  This  supination  will  assist  in 
preventing  the  bones  becoming  locked  close  together  (see  Fig. 
261). 

In  order  to  immobilize  a  fracture  of  the  shaft  of  a  bone  not 
only  must  the  fracture  itself  be  held  firmly,  but  the  joint  im- 
mediately above  and  below  the  seat  of  fracture  must  Ix-  im- 
movably fixed.  If  the  arm  is  seen  immediately  after  the  ac- 
cident, and  the  soft  parts  are  not  evidently  bruised,  and  there 
is  little  swelling,  a  plaster-of- Paris  splint  should  be  applied. 
It  should  extend  from  the  axilla  above  to  the  metacarpopha- 
langeal joints  below.  The  arm  should  be  flexed  to  a  right  angle 
and  the  forearm  semisupinated  (thumb  upward)   (see  Fig.  262). 

Precautions  in  Using  the  Plaster-of- Paris  Splint:  The  fore- 
arm should  be  held  in  the  corrected  position  by  an  assistant 
throughout  the  application  of  the  plaster  bandages.  Two  as- 
sistants will  facilitate  the  putting  on  of  the  plaster.  The  fore- 
arm and  upper  arm  should  be  thinly  covered  with  one  layer  of 
sheet  wadding;  cotton  wadding  should  not  be  used.  No  salt 
should  be  used  in  the  water  in  which  the  plaster  bandages  are 
dipped.  It  will  require  about  three  or  four  bandages,  three 
inches  wide  and  four  yards  long,  for  an  ordinary  muscular  adult 
arm.  The  plaster  roller  should  be  applied  deliberately,  e\-enly, 
and  snugly  from  the  metacarpophalangeal  joints  to  the  axilla. 
Great  lateral  compression  of  the  arm  will  be  avoided  if  the  ban- 
age  is  applied  as  directed.  There  will  be  insufiicient  compres- 
sion to  crowd  the  bones  together  and  so  produce  deformity. 

After-care  of  the  Plaster  vSplints:  When  the  plaster  has  set 
firmly,  the  assistant  may  place  the  forearm  in  a  sling  of  com- 
fortable height  to  support  the  arm.  Inspection  of  the  fingers 
will  determine  the  condition  of  the  circulation  in  the  limb.  If 
there  is  too  great  pressure,  if  the  splint  is  too  tight,  a  blueness 
will  appear,  indicating  a  sluggishness  in  the  circulation.  If 
this  sign  appears,  the  splint  should  immediately  be  split  from 
axilla  to  hand  by  a  knife.  This  will  relieve  the  circulation. 
Ordinarilv,  there  is  no  difficulty  of  this  sort.     The  patient  should 


212       FRACTl'RES  OF  THE  BONES  OK  THE  FOREARM 

be  seen  each  day  for  the  first  week  after  the  dressing  is  put  on. 
Inquiry  should  be  made  for  pain  and  throbbing  in  the  arm  and 
sleeplessness,  which  are  e\'idences  of  too  great  pressure.  If  the 
arm  is  doing  well,  the  splint  should  cause  no  discomfort.  After 
one  week  the  plaster  splint  should  be  removed,  for  the  swelling 
of  the  arm  will  have  diminished  and  the  splint  will  have  become 


Fig.  260. — Variations  in  the  shape  and  width  of  the  interosseous  space  between  radius  and 
ulna  when  the  forearm  is  supinated,  pronated,  and  semipronated.  Semipronation  presents 
the  widest  interosseous  space  (diagram). 


loosened.  Unless  this  loosening  is  corrected,  an  opportunity 
for  deformity  to  occur  will  then  exist.  Rither  a  new  plaster 
should  be  applied  or  the  old  splint,  if  suitable,  should  be  reapplied 
and  tightened  by  a  bandage.  If  the  splint  is  too  large,  it  may 
be  made  smaller  by  removing  a  strip  of  plaster  the  entire  length 
of  the  splint.  The  edges  of  the  cut  plaster  should  be  bound 
with  strips  of  adhesive  plaster  to  prevent  chafing  of  the  skin 


TREATMENT 


2  1,3 


and  crumbling  of  the  plaster.  The  position  of  the  bones  at  the 
seat  of  fracture  should  be  noted.  The  degree  of  movement 
possible  at  the  seat  of  fracture  should  be  noted.  At  the  end  of 
each  week  the  splints  should  be  removed.  After  about  three 
weeks,  when  union  is  well  advanced,  the  plaster  splint  may  be 


Fig.  261. — Fracture  of  the  forearm  low  down,  or  Colles'  fracture.     Anterior  and  posterior 
splints,  three  straps,  radial  pad.     Anterior  splint  cut  out  to  fit  thenar  eminence. 


Fig.  262. — Fracture  of  the  forearm.     Manner  of  holding  arm  and  of  applying  the  adhesive- 
plaster  .straps.     Posterior  splint  of  splint  wood. 


cut  off  below  and  the  upper  part  discarded,  or  a  posterior  splint 
of  wood  may  be  applied  for  lightness  and  convenience. 

If  the  force  was  a  direct  violence  and  there  is  injury  to  the 
soft  parts,  if  the  swelling  is  considerable  and  is  likely  to  be  greater, 
it  will  be  best  to  use  palmar  and  dorsal  splints  of  wood  upon  the 
forearm  and  an  internal  right-angle  splint  at  the  elbow.     The 


214 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


forearm  is  held  in  llie  position  of  semisupinalion.  The  niaxiinuin 
swelling  oeenrs  williin  tlie  first  forty-eight  hours — barring,  of 
course.  inllamniator\-  cHsturbances,  which  are  not  to  be  con- 
sidered here.  The  splints  should  be  of  thin  splint  wood,  which 
is  stiff  enough  not  to  yield  to  ordinary  pressure.  In  width 
thev  should  be  one-fourth  of  an  inch  wider  than  the  forearm. 
The  posterior  splint  should  extend  from  just  above  the  middle 
of  the  forearm  to  the  metacarpophalangeal  joints.     The  anterior 


Fig.  263. — FracUirc  of  Imtli  buiies  ol  the  loreiinn.     Proper  position  of  arm  in  sling.     Note  IuukI 
is  unsupported  b\-  sling,  and  arm  rests  on  ulnar  side.     Xotiee  height  of  arm. 


splint  should  extend  from  the  same  point  on  the  forearm  to  the 
middle  of  the  palm  of  the  hand  (see  Fig.  261).  The  palmar 
splint  is  cut  out  on  the  thumb  side,  so  as  to  avoid  pressure  on 
the  thenar  eminence.  These  two  splints  are  padded  with  evenly 
folded  sheet  wadding  no  wider  than  the  splints.  About  three 
or  four  thicknesses  of  the  sheet  wadding  will  be  necessar)-.  The 
posterior  splint  is  padded  alike  through  its  whole  extent.  The 
anterior  splint  is  so  padded  as  to  conform  to  the  irregularities 
of  the  anterior  surface  of  the  forearm,  particularly  at  the  radial 


TRPCATMUNT 


2  1.5 


side  near  the  wrist.  The  internal  right-angle  splint  is  padded 
evenly  with  four  thicknesses  of  sheet  wadding.  It  overlaps 
the  wooden  splints,  and  extends  up  to  the  axilla.  It  immobilizes 
the  elbow- joint. 

The  Application  of  the  vSplints:  The  forearm  is  held  Hexed  at 
a  right  angle  and  semisupinated  and  steadied  by  an  assistant. 
The  posterior  and  then  the  anterior  splints  are  applied  to  the 
forearm.  Three  straps  of  adhesive  plaster,  two  inches  broad, 
are  then  applied — one  at  the  upper  ends  of  the  splints,  one  at  the 
wrist,   and  the  third  across  the  palm  of  the  hand  and  around 


Fig.  264. — Fracture  of  both  bones  of  the  forearm.  Uhiar  view  of  the  anterior  and  posterior 
splints.  Note  length  of  splints  and  position  of  straps.  Straps  of  the  internal  right-angle 
splint,  3  and  4. 


the  posterior  splint  only.  These  straps  should  simply  steady 
the  splints  snugly  in  position  (see  Fig.  262).  The  bandage  is 
next  applied,  and  it  is  by  this  that  pressure  is  exerted  upon  the 
arm.  There  should  be  some  spring  left  upon  pressing  the  splints 
together  after  the  bandage  is  applied.  If  there  is  none  remaining, 
too  great  pressure  will  be  made  on  the  arm  and  the  circulation 
will  be  interfered  with.  The  arm  is  placed  in  a  sling  of  com- 
fortable height  (see  Fig.  263). 

If  the  fracture  of  the  forearm  is  above  the  middle  of  the  bones, 
the  tin  internal  right-angle  splint  should  be  used  to  immobilize 


2l6       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

the  elbow- joint.  This  should  be  applied  after  the  wooden  splints 
are  in  place  and  while  the  arm  is  semisupinated.  A  bandage  is 
then  placed  over  both  wooden  and  tin  splints  (see  Pigs.  264, 
265,   266). 

After-care  of  Wooden  and  Tin  Splints:  The  patient  should  be 
seen  every  day  for  two  or  three  davs  after  the  fracture.  The 
splints  should  be  readjusted  and  applied  more  snuglv  by  a  fresh 
bandage.  The  comfort  of  the  patient  should  be  considered; 
any  complaint  on  the  part  of  a  sensible  individual  should  be  in- 


Fig.  265. — Fracture  of  the  bones  of  forearm.  Forearm  supiiiated.  Anterior  and  posterior 
splints  and  tin  internal  angular  splints,  i  and  2,  Straps  holding  anterior  and  posterior  splints; 
3,  4,  and  5,  straps  holding  internal  right-angle  splint. 


quired  into.  If  the  apparatus  is  applied  with  the  bones  in  ap- 
proximatelv  normal  position,  there  should  be  no  subsequent 
discomfort.  All  splints  should  be  removed  at  least  twice  a  week 
throughout  active  treatment,  and  the  presence  of  deformity 
noted  and  corrected.  After  the  first  week  and  a  half,  the  swell- 
ing having  subsided,  it  is  often  advantageous  to  apply  in  place 
of  these  splints  of  wood  the  plaster-of-Paris  splint,  which  has 
been  described. 

Fracture  of  the  head  and  neck  of  the  radius  and  fractiire  of  the 


TREATMENT 


217 


coronoid  process  of  the  ulna  should  be  treated  by  the  internal 
right-angle  splint  with  the  forearm  semipronated— that  is,  with 
the  thumb  up  (see  Fig.  266). 

Fracture  of  the  shaft  of  the  radius,  if  above  the  middle  of  the 
bone,  should  be  treated  by  the  anterior  and  posterior  wooden 
spHnts  and  the  internal  right-angle  splint.  If  below  the  middle 
of  the  bone,  the  internal  right-angle  splint  may  be  omitted,  al- 
though it  may  be  well  to  retain  it  in  most  instances.  If  the 
fracture  is  in  the  upper  third  of  the  bone,  it  may  be  impossible 
to  correct  the  deformity  without  making  an  open  fracture  and 
suturing   the  fragments   together.     It   may   be   possible   to   ap- 


Fig.  266.— Fracture  of  both  bones  of  the  forearm.  Anterior  and  posterior  splints  and  tin 
internal  right-angle  splint  immobilizing  elbow-joint.  Note  arm  in  semipronation,  "  thumb 
up  "  ;  position  of  straps  ;  padding  of  internal  right-angle  splint. 


proximate  the  fragments  by  putting  the  forearm  in  a  position 
of  semipronation.  No  special  splint  is  necessary  to  maintain 
this  position;  the  two  wooden  anterior  and  posterior  splints  and 
the  tin  internal  right-angle  splint  fulfil  all  the  indications. 

Separation  of  the  lower  radial  epiphysis  is  treated  by  anterior 
and  posterior  splints,  similarly  to  the  treatment  of  a  Colles' 
fracture  (see  Fig.  274). 

Fracture  of  the  shaft  of  the  ulna  should  be  treated  as  fractures 
of  the  shaft  of  the  radius  are  treated- 

How  long  should  splints  be  kept  on  in  fractures  of  the  fore- 
arm?    Until  union  is  firm  enough  between  the  fragments,    so 


2l8  KRACTLRKS    OK    THE    IK)NES    OF    TIIH    FORICARM 

lluil  finn  i)ressure  docs  not  cause  motion.  Wlicn  llic  fracture 
is  firm,  ordinarily  after  about  three  weeks  and  a  half,  the  anterior 
and  internal  angular  splints  may  be  omitted,  the  posterior  splint 
alone  being  left  in  place.  If  the  posterior  splint  of  wood  is  used, 
a  broad  (four-inch)  strap  of  adhesive  plaster,  in  addition  to  the 
two  ordinary  straps  at  each  end  of  the  splint,  shoidd  be  placed 


Fig.  267.— Applicalion  of  sliiig.  Proper  position  of  triangular  bandage  in  fust  sUp.  2  is 
carried  over  right  shoulder ;  i  drops  over  left  shoulder  ;  i  and  2  are  fastened  behind  the  neck  ; 
3  is  brought  forward  and  pinned,  as  shown  in  figure  26S. 

at  the  seat  of  fracture  and  a  gauze  bandage  applied  over  all.  At 
the  end  of  the  fourth  or  fifth  week  all  splints  should  be  omitted. 
Continual  watchfulness  is  demanded  in  order  that  bowing  at  the 
seat  of  fracture  may  not  take  place.  The  application  of  the 
sling  after  the  omission  of  splints  should  be  carefully  made  to 
avoid  backward  bowing  of  the  bones.  A  laboring  man  should 
not  "fo  to  work  for  at  least  from  four  to  six  weeks  after  leaving 


TREATMENT 


219 


off  splints.  A  return  to  work  too  early  causes  bowing  of  the 
fracture  and  pain  in  the  arm. 

Massage  and  passive  motion  should  be  employed  as  soon  as 
union  is  firm  and  the  anterior  and  internal  angular  splints  have 
been  removed.  Massage  may  be  given  at  first  without  removing 
the  arm  from  the  splint.  Convalescence  will  proceed  more 
rapidly  in  consequence  of  massage. 

When  will  the  arm  be  restored  to  normal  usefulness?     It  is 


Fig.  26S. — Application  of  sliii^ 


Final  position  of  arm.     fwo  ends  tied  behind  neck  and  the 
third  end  pinned. 


impossible  to  answer  this  question  accurately.  The  conditions 
in  each  individual  instance  of  fracture  are  so  variable  that  no 
general  statement  can  be  made  that  will  more  than  indicate 
the  probable  time  of  convalescence.  It  may  be  fairly  stated  that 
in  an  uncomplicated  fracture  of  both  bones  of  the  forearm  the 
arm  will  be  useful  for  working  in  from  two  to  three  months  from 
the  time  of  fracture. 

The  treatment  of  open  fractures  of  the  forearm  is  best  con- 


2  20  FRACTl-RES    OF    THE    BONES    OF   THE    FOREARM 

ducted  bv  methods  described  under  open  fractures  of  the  leg: 
brielly.  absokite  cleanliness,  suturing  of  bones,  sterile  dressing, 
immobilization  of  the  part. 

Prognosis  and  Result  of  Treatment. — There  may  be  some 
limitation  of  supination  and  pronation  immediately  after  the 
splints  are  removed.  As  the  callus  diminishes  and  with  per- 
sistent movements  of  the  arm  in  ordinary  use  this  limitation 
should  diminish,  and  in  some  instances  entirely  disappear.  If 
the  fracture  is  in  the  upper  or  lower  thirds  of  the  bones,  the 
limitation  of  motion  will  often  be  greater  than  when  the  fracture 


Fig.  269. — Compound  fracture  and  dislocation  at  the  wrist.     Hand  saved. 


is  at  the  middle  of  the  bones.  The  interosseous  space  is  greatest 
at  the  middle  of  the  shafts  (see  Fig.  260) ;  consequently,  callus 
at  this  point  is  less  likely  to  impair  motion  of  the  forearm.  The 
arm  should  be  straight.  Movements  of  the  wrist  and  elbow 
should  be  perfectly  normal. 

Nonunion  of  Fractures. — If  after  the  usual  time  has  elapsed 
for  a  fracture  to  have  united  firmly  it  has  failed  of  union,  de- 
layed union  is  said  to  exist.  If  after  a  longer  time  no  union 
occurs,  nonunion  is  said  to  exist.  A  case  of  delayed  union  may 
result  in  nonunion  or  it   mav  become  united.     The  term  non- 


PROGNOSIS   AND    RESULT    OF    TREATMENT  221 

union  does  not,  however,  necessarily  imply  that  no  union  exists 
between  the  bones,  but  simply  that  bony  union  does  not  exist. 
In  cases  of  so-called  nonunion  fibrous  union  is  often  present. 
The  causes  of  nonunion  are  local  and  general.  Of  the  local  causes 
the  commonest  is  the  interposition  of  some  soft  tissue,  such  as 
torn  periosteum,  strips  of  fascia  or  muscle,  between  the  frag- 
ments. A  wide  separation  and  imperfect  immobilization  of 
the  fragments  are  also  factors  in  the  occurrence  of  nonunion. 
Of  the  general  causes  it  is  thought  that  syphilis,  pregnancy,  pro- 
longed lactation,  the  wasting  diseases,  rachitis,  and  the  acute 
febrile  diseases  may  contribute  something  toward  nonunion. 

The  constitutional  treatment  of  nonunion  is  of  primary  im- 
portance, together  with  reduction  and  absolute  immobilization 
of  the  fragments.  If  these  measures  fail  after  a  fair  trial,  a 
rubbing  of  the  ends  of  the  fractured  bones  together  and  then 
immobilizing  them  is  sometimes  effective.  If  this  fails  too, 
operative  measures  should  be  instituted  for  making  the  fracture 
an  open  one  for  the  removal  of  any  interposed  tissues.  Careful 
fixation  will,  after  such  operative  procedure,  usually  effect  union. 
If  for  some  unremediable  constitutional  reason  union  does  not 
result  after  operation,  a  splint  should  be  devised  to  make  the 
damaged  part  as  useful  as  is  compatible  with  nonunion. 

Treatment  of  Greenstick  or  Incomplete  Fracture  of  the  Bones  of 
the  Forearm.. — It  is  impossible  to  maintain  the  correction  of  the 
deformity  if  the  bones  are  simply  bent  back  into  position.  Even 
with  the  greatest  care  in  the  use  of  pads  and  pressure  the  de- 
formity will  in  part  reappear.  It  is  necessary,  therefore,  to 
administer  an  anesthe'tic,  and  to  make  a  complete  fracture  of 
the  greenstick  fracture.  This  done,  the  arm  is  set  as  in  a  com- 
plete fracture.  The  best  method  of  refracturing  the  greenstick 
fracture  is  to  bend  the  arm  with  the  two  hands  in  the  direction 
of  the  original  force. 

The  anterior  and  posterior  wooden  splints  may  be  used  with 
satisfaction.  Ordinarily,  the  plaster-of- Paris  splint  as  applied 
in  complete  fractures  is  the  best  apparatus.  Union  in  children 
after  fracture  is  more  rapid  than  in  adults.  At  the  end  of  two 
weeks  union  will  be  foimd  firm.  It  is  well  not  to  omit  all  ap- 
paratus in  a  child  until  four  weeks  have  passed.     If  great  caution 


222       !"RACTlRi:s  OF  THE  BONES  oK  THE  KORKAKM 

is  needed  (in  aeconnt  of  an  extremely  aetivo  ehild,  the  posterior 
wooden  si)Hnt  should  be  kept  on  chirins:  the  fifth  ^veek. 


Fig.  270. — Showing  relatiuiLs  of  olecranon  to  elbow-joint  ;  practically  all  fractures  are  intra- 
articular. 


Seat  of  fracture. 
Fig.  271. — Splintered  fracture  of  olecranon  without  much  displacement  f^Tassacln^setts  Gen- 
eral Hospital,  1536.     X-ra>-  tracing). 


FRACTURES  OF  THE  OLECRANON 

The  normal  anatomical  relations  of  the  olecranon  should  be 
kept  constantly  in  mind.     The  insertion  of  the  brachialis  anticus 


FRACTURES  OF  THE  OLECRANON 


223 


muscle  is  into  the  front  and  lower  part  or  base  oi  the  coronoirl 
process  of  the  ulna.     The  insertion  of  the  triceps  muscle  is  into 


Radius. 


Coionoid  process. 


Ulnar  shaft. 


U    Hi 


Seat  of  fracture. 


Fig.  272.— Fracture  of  olecranon.     No  displacement  detected  clinically.     No  symptoms  other 
than  local  tenderness  and  slight  swelling  (X-ray  tracing). 


Olecranon. 


Ulnar  shaft. 
Fig.  273. — Fracture  of  olecranon  ;  separation  of  fragments  upon  Hexing  forearm  (X-ray 

tracing.) 


the  posterior  part  of  the  upper  surface  of  the  olecranon   and 
into   the   fascia   of  the   posterior   surface   of  the  forearm.     The 


224 


FRACTURns  OF  THE  BONES  OF  THE  FOREARM 


small  epiphysis  of  the  olecranon  unites  to  the  shaft  about  the 
sixteenth    year.     A    direct    blow    upon    the    olecranon    together 


Line  of  fracture. 
Fig.  274. — Fracture  of  olecranon  at  about  the  epiphyseal  line,  without  opening  the  elbow-joint 
(Massachusetts  General  Hospital,  1172.     X-ray  tracing). 


Fig.  275. — Diagrams  to  illustrate  separation  of  fragment  of  olecranon  by  the  triceps  and  in 

flexion  of  the  elbow. 


with  violent   muscular  contraction   of   the  triceps  will  produce 
the  fracture.     The  fracture    is   usually  transverse.     A  complete 


SYMPTOMS  225 

transverse  fracture  of  the  olecranon  always  opens  the  elbow- 
joint  (see  Fig.  269).  Some  of  the  varieties  of  fracture  of  the 
olecranon  are  seen  in  the  accompanying  tracings  of  Rontgen-ray 
plates  (see  Figs.  271,  272,  273,  274). 

Symptoms. — Inability    forcibly    to    extend    the    forearm,    pain 
at  the  seat  of  fracture,  and  deformity,   provided  the  fragment 


Fig.  276. — Fracture  of  the  olecranon.     Arm  in  extension.     Long  anterior  splint.     Note  pad 
and  strap  above  olecranon  fragment ;  pad  in  palm  of  hand. 


is  separated  from  the  shaft  of  the  ulna.  A  depression  marks 
the  separation.  Very  great  separation  of  the  fragment  is  not 
often  present.  The  interval  between  the  fragments  depends 
upon  three  conditions:  The  extent  of  the  facial  laceration — if 
the  laceration  is  moderate  in  extent,  the  interval  between  the 
fragments  will  be  shght;  if  the  laceration  is  extensive,  the  in- 
terval between  the  fragments  may  be  great;  the  position  of  the 
15 


(26 


FRACTURES    or    TIIU    BONKS    OF    THE    FOREARM 


arm,  whether  Hexed  or  exteiuled — if  Hexed,  the  separation  will 
he  greater  than  if  extended  (see  Fig.  275) ;  the  amount  of  synovial 
lluid  and  blood  in  the  joint — the  greater  the  amount  of  lluid, 
the  greater  will  be  the  separation  of  the  fragments.  The  mobility 
of  the  fragments  of  the  olecranon  is  determined  by  grasping  the 
olecranon  firmly  and  attempting  lateral  motion   (see  Fig.    194). 


Fig.  277. — Fracture  of  olecranon.     Arm  in  extension.     Note  ujjjier  and  lower  .straps  ;  oblique 
olecranon  strap  ;  padding  of  splint. 


Crepitus  may  thus  be  elicited.  The  general  swelling  about  the 
elbow-  will  be  considerable  if  the  traumatism  was  severe.  There 
exists  a  traumatic  synovitis  of  the  elbow- joint. 

Treatment. — If  there  is  considerable  swelling  of  the  elbow, 
and  if  the  arm  is  large  and  muscular,  it  is  wise  to  rest  the  arm 
for  a  few  days  (at  least  live  or  six)  upon  an  internal  right-angle 
splint  before  putting  it  up  permanently.     The  swelling  will  dis- 


trkatmknt  227 

appear  in  the  mean  time,  and  a  more  aceurate  examinaiicjii  <>i 
the  arm  can  then  be  made.  If  there  is  little  or  no  separation 
of  the  fragments  in  the  right-angle  position,  the  arm  may  be 
kept  at  a  right  angle.  This  is  doubtless  the  most  comfortable 
position,  and,  under  these  conditions,  certainly  is  effective.  If 
there  is  marked  separation  (half  an  inch  or  more),  the  arm  should 


Fig.  27S. — Fracture  of  olecranon.     Bandage  applied  to  the  same  case  as  shown  in  figures  276, 
277.     Note  protection  of  fingers  from  chafing  by  compress  cloth  and  bandaging  of  hand. 


be  extended  and  this  position  maintained  bv  a  long  internal 
splint  (see  Fig.  276).  This  splint,  made  of  splint- wood,  should 
be  the  width  of  the  arm,  and  should  reach  from  the  anterior 
axillary  margin  to  the  tips  of  the  fingers.  This  is  well  padded 
with  sheet  wadding  at  the  bend  of  the  elbow  (see  Fig.  277).  The 
contiguous  skin  surfaces  of  the  fingers  are  protected  from  chafing 
by  strips  of  gauze  or  compress  cloth  placed  between  them,  and 


228      .FRACTURES  OF  THE  BONES  OF  THE  F(^REARM 

a  pad  is  put  in  the  palm  for  comfort  (see  lug.  27S).  The  splint 
is  held  in  position  by  four  straps  of  adhesive  plaster,  one  placed 
at  either  end  of  the  splint  and  one  above  and  below  the  elbow- 
joint.  The  upper  or  loose  fragment  is  pushed  down  toward  the 
shaft  of  the  ulna,  and  held  in  place  by  a  strap  of  adhesive  plaster 
carried  around  the  upper  side  of  the  olecranon  fragment  and 
fastened  to  the  splint  lower  down.     Sheet  wadding  and  gauze 


Fig.  279. — Supination.     Compare  with  figure  281.     Note  the  relative  positions  of  styloid  pro- 
cesses of  ulna  and  radius.     The  two  styloids  are  palpated  in  this  position. 


roller  bandages  applied  from  the  fingers  to  the  axilla  afiford 
comfort  and  prevent  undue  swelling  of  the  hand.  Should  the 
separation  be  so  great  that  reduction  of  the  fragment  is  un- 
satisfactory, an  incision  and  suture  should  be  made  (see  Fig.  278). 
Treatment  if  the  Fracture  is  Open. — The  wound  should,  if 
necessary,  be  enlarged  to  permit  of  easy  inspection  of  the  joint 
surface.  The  joint  should  be  thoroughly  irrigated  with  boiled 
water.     The  wound  of  the  soft  parts  should  be  very  thoroughly 


TREATMENT  229 

cleansed  by  scrubbing  with  gauze  wet  in  corrosive  sublimate 
solution,  I  :  5000,  and  then  the  fragment  of  the  olecranon  suturerl 
to  the  shaft. 

The  After-care. — If  the  arm  has  been  put  up  temporarily  at  a 
right  angle  to  await  the  subsidence  of  the  swelling,  gentle  mas- 
sage and  firm  bandaging  of  the  arm,  twice  daily,  until  the  swell- 
ing subsides  sufficiently  for  accurate  examination   and   a  more 


Fig.  280. — Pronation.     Compare  figure  282.     Note  that  palpating  fingers  feel  styloid  of  radius 

and  head  of  ulna. 


permanent  dressing,  will  be  of  very  great  service.  The  arm 
should  be  inspected  each  day  for  the  first  week.  Daily  massage 
should  be  continued  not  only  to  the  joint  region,  but  to  the 
forearm  and  upper  arm  as  well.  The  straps  and  bandages  should 
be  reapplied  as  they  become  too  tight  or  are  loosened  by  the 
disappearance  of  the  swelling.  After  about  two  weeks  the 
position  of  the  forearm  may  be  cautiously  changed.  The  small 
fragment  of  the  olecranon  should  be  held  fixed  during  the  ma- 


230 


FRACTIKICS    OF    THE    BONES    OF    THE    FOREARM 


nipiilation.  If  the  arm  is  in  the  extended  position,  il  should 
be  gradually  Hexed  some  five  or  ten  degrees,  and  returned  to  the 
extended  position.  If  the  arm  is  already  at  a  right  angle,  it 
should  be  gradually  extended,  at  first  a  few  degrees  only,  and 
returned  to  tlie  right-angle  position.  No  pain  should  be  ex- 
perienced by  the  passive  motion.  Painful  passive  motion  is 
harmful.  After  a  few  days  of  these  gentle  passive  motions  it 
will  be  wise  to  alter  the  angle  of  the  splint  so  that  the  arm  may 


F'ig.  2S1. — Method  of  e.xamination  of 
wrist.  Note  supination  of  forearm  ;  posi- 
tion of  examining  hands  and  fingers  ;  pal- 
pation of  the  .styloid  process  of  the  radius 
and  the  head  of  the  ulna.  The  radial  sty- 
loid is  seen  to  be  lower  than  the  head  of 
the  ulna. 


Fig.  282. — Method  of  examination  of 
wrist.  Note  pronation  of  forearm ;  posi- 
tion of  examining  hands  and  fingers  ;  pal- 
pation of  styloid  processes  of  radius  and 
ulna.  The  styloid  of  the  radius  is  lower 
than  the  styloid  of  the  ulna. 


rest  in  the  changed  position  permanently.  After  about  four 
or  five  weeks  all  splints  should  be  omitted.  A  bandage  should 
be  worn  after  the  removal  of  the  splints  to  afford  support  to 
the  elbow. 

Union  of  the  fragments  usually  takes  place  in  from  three  to 
four  weeks.  After  six  weeks  to  three  months  the  movements 
of  the  elbow- joint  should  be  normal.  There  may  remain  as  a 
permanent  condition  slight  limitation  of  extension.     The  func- 


TREATMENT 


231 


tional  usefulness  of  the  elbow  depends  more  upon  the  approxi- 
mation of  the  fragments  and  less  upon  the  kind  of  union  be- 
tween them.  The  union  between  the  fragments  is  more  often 
ligamentous  than  bony.  The  short  fibrous  union,  if  of  good 
width, — i.  e.,  if  it  covers  the  whole  of  the  broken  surface, — is  as 
efficient  as  a  bony  union.  A  ligamentous  union  accompanied 
by  great  disability  in  the  functional  usefulness  of  the  arm  should 
be  excised  and  the  bony  fragment  sutured  to  the  shaft.  vSutur- 
ing  of  the  periosteum  and  fibrous  tissue  about  the  fragments 
will  prove  fully  as  satisfactory  in  many  cases  as  suturing  the 
bone  with  silver  wire. 

Summary:  If  there  is  great  swelling,  delay  the  application  of 
the  permanent  splint.     Apply  internal  right-angle  splint.     Use 


Fig.  2S3. — Method  of  examination  in  a  case  of  injurj-  to  the  lower  end  of  the  radius.     Grasp- 
ing the  radius  above  and  below  the  probable  seat  of  fracture. 


compression  and  massage.  If  there  is  little  or  no  separation  of 
the  fragments,  use  a  right-angle  splint.  If  there  is  marked 
separation  of  fragments,  use  an  extended  position.  If  the  fracture 
is  open,  suture  the  fragments.  If  practicable,  at  the  outset, 
renew  the  bandage  and  massage  the  arm  twice  daily.  After 
two  weeks  cautious  passive  motion  should  be  made  daily.  After 
three  weeks  the  angle  of  the  splint  should  be  permanently  changed. 
After  four  weeks  all  splints  should  be  removed.  After  six  weeks 
to  three  months  a  useful  arm  should  result. 

Tetanus  is  rarely  seen  after  fracture  of  bone.  It  sometimes 
appears  after  open  fracture.  Early  amputation  and  the  ad- 
ministration of  tetanus  antitoxin  are  the  most  rational  means 
of  treatment  in  these  cases. 


232  FRACTURES    OF    THE    BONES   OF   THE    FOREARM 

COLLES'  FRACTURE 

A  fracture  of  the  lower  end  of  the  radius  within  about  one 
inch  of  the  articular  surface  is  common  in  adults  and  is  unusual 
in  childhood.  A  fall  upon  the  outstretched  and  extended  hand 
is  the  most  frequent  cause. 

Anatomy. — In  a  case  of  traumatism  to  the  wrist  the  normal 
anatomical  relations  should  be  studied  upon  the  uninjured  wrist, 


Fig.  284. — Diagram  of    fracture  of  base  of    radius  with   anterior  displacement;  "reversed 
Colles'  fracture"  (term  suggested  by  Roberts). 


Fig.  285. — Colles' fracture  ;  the  common  "  silver-fork   deformity."     Note  dorsal  and  palmar 
prominences  (diagram). 


and  then  a  careful  examination  made  of  the  injury.  The  normal 
wrist  should  be  looked  at  from  the  front  and  back  and  from  each 
side  with  the  hand  supinated.  Anteriorly,  the  base  of  the  thenar 
eminence  is  lower  than  that  of  the  hypothenar  eminence.  Pos- 
teriorly, on  the  inner  side,  the  styloid  process  of  the  ulna  is  visible 
with  the  marked  depression  below  it.  Laterally,  on  the  radial 
side,  is  seen  the  curve  backward  on  the  anterior  surface  of  the 
radius  where  the  base  of  the  styloid  process  of  the  radius  joins 
the  shaft.     Laterally,  upon  the  ulnar  side,  are  seen  not  only  the 


COLLES'    FRACTURE — ANATOMY 


233 


styloid  of  the  ulna  and  its  associated  depression,  but  the  hollow 
above  the  prominence  of  the  hypothenar  eminence. 

The  normal  wrist  should  be  felt  with  the  hand  both  in  supina- 
tion and  pronation.     With  the  hand  supinated    (see   Fig.    281) 


Fig.  286.— Colles'  fracture.     Characteristic  appearance.     Note  backward  displacement  of  the 
hand  and  wrist.     Palmar  prominence.     Compare  with  figure  285. 


Fig.  287.— CoUes'  fracture,  radial  side.    Marked  crease  at  base  of  thumb.    Dorsal  and  palmar 

prominences. 


Fig.  288.— Colles'  fracture,  ulnar  side.    Absence  of  ulna  on  the  dorsum  of  the  wrist ;  presence 
anteriorly.     Marked  crease  in  front  of  displaced  ulna.     Dorsal  prominence  marked. 


the  tip  of  the  styloid  process  of  the  radius  is  found  to  be  lower 
(nearer  the  hand)  than  the  head  of  the  ulna.  With  the  hand 
in  pronation  (see  Fig.  282)  the  tip  of  the  styloid  process  of  the 
radius  is  found  to  be  a  little  lower  (nearer  the  hand)  than  the  tip 


?34 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


of  the  styloid  process  of  the  uhia.  To  ascertain  the  relative 
position  of  the  styloid  processes,  the  injured  wrist  should  be 
grasped  bv  the  two  hands  and  the  styloids  felt  by  the  tips  of  the 
forelingers.  The  styloid  process  of  the  radius  and  the  shaft 
immediately  above  it  should  be  carefully  palpated  to  determine 
the  extreme  thinness  of  the  bone  above  the  thick  styloid  process 
(see  Fig.  2 S3).     The  width  of  the  wrist  between  the  styloid  pro- 


Fig.  289.  —  Colles' 
fracture,  anterior  bulg- 
ing of  flexor  tendons ; 
absence  of  dorsal  prom- 
inence of  head  of  ulna. 


Fig.  290. — Colles'  fracture. 
The  dorsal  prominence  is  not 
uncommonly  seen  after  recov- 
ery from  fracture  of  the  radius 
when  the  displaced  bones  have 
been  but  partially  reduced. 
Slight  lateral  deformity. 


Fig.  291. — Colles'  fracture. 
Hand  carried  to  radial  side. 
Prominent  ulna  anteriorly. 
Thenar  eminence  lower  than 
normal. 


cesses  should  be  measured  by  means  of  a  tape,  or,  better,  by  a 
pair  of  calipers. 

The  movements  of  the  normal  wrist  and  forearm  should  be 
carefull}^  observed.  Pronation  and  supination  of  the  forearm 
and  flexion,  extension,  abduction,  and  adduction  of  the  hand 
should  be  carefully  performed.  These  simple  observations 
quickly  made  upon  the  normal  wrist  enable  one  to  establish  a 
standard  for  comparison  with  the  injured  wrist.  In  every  case 
in  which  there  is  a  question  of  fracture  the  examination  should 
be  made  by  means  of  an  anesthetic  (see  Fig.  283).     If  for  sufificient 


COLLES'  PRACTURE — SYMPTOMS 


^35 


reason  complete  anesthesia  is  contraindicated,  primary  anesthesia 
will  prove  to  be  sufficient.  In  the  larger  proportions  of  cases 
of  Colles'  fracture  primary  anesthesia  will  be  satisfactory  for 
both  the  examination  and  the  first  dressing  of  the  fracture. 

Symptoms. — In  Colles'  fracture  the  wrist  appears  unnatural. 
The  thenar  eminence  of  the  thumb  is  higher,  nearer  to  the  wrist 
than   usual,    as  compared   with   the   hypothenar   eminence    (see 


Fig.  292.— A  form  of   comminution    in   Colles'  frdcture.     Left  wrist  from  back   and   below 

(diagram). 


Line  of  fracture 

T-line 

Lower  radial  fragment 


Styloid  process  of  ulna. 


Fig.  293.— Colles'  fracture.     Anteroposterior  view.     Slight  lateral  deformity.     Anterior  view 
of  figure  294  (Massachusetts  General  Hospital,  1028.    X-ray  tracing). 


Fig.  291).  Anteroposterior  and  lateral  deformities  are  apparent 
to  a  greater  or  less  degree.  It  is  said  that  at  times  an  anterior 
displacement  of  the  lower  fragment  occurs,  the  reverse  of  the 
ordinary  displacement.     It  is  unusual  (see  Fig.  284). 

The  anteroposterior  deformity  is  caused  by  the  projection  of 
the  lower  end  of  the  upper  fragment  into  the  palmar  surface  of 
the  wrist,   pushing  the  flexor  tendons  forward    (see   Fig.    2S5), 


36 


FRACTl'RES  OF  THE  BONES  OF  THE  FOREARM 


and  by  the  projection  of  the  upper  end  of  the  lower  fragment 
toward  the  dorsal  surface  of  the  wrist,  pushing  the  extensor 
tendons  backward.  Impaction  of  the  radial  fragments  may  be 
another  factor  in  the  production  of  the  deformity.     This  deformity 


Lower  radial  fragment  rotated. 
I    Scaphoid. 


Radius 


Ulna. 


First  metacarpal. 

I 

Carpus. 


Styloid  of  radius. 

Fig.  294. — CoUes'  fracture.    Lateral  view  of  figure  293.     Rotation  of  lower  fragment  on  trans- 
verse axis.     Cause  of  dorsal  and  palmar  deformity  evident  (X-ray  tracing). 


Lower  fragment  of 
radius. 


Fig.   295.— Simple   transverse    Colles'   fracture.      Anteroposterior  view.     Lateral   deformity 

(X-ray  tracing). 


is  spoken  of  by  the  older  writers  as  the  silver-fork  deformity. 
The  reason  is  obvious  (see  Figs.  286,  287,  288,  289,  290). 

The  lateral  deformity  (see  Fig.  291)  is  caused  by  several  factors: 
the  impaction  of  the  radial  fracture,  lateral  displacement  of  the 
lower  fragment,  and  by  rupture  of  the  inferior  radioulnar  liga- 
ments.    The    abduction    of    the    whole    hand,    the    prominence 


'Tl  1> 


O    < 


238 


FRACTIRKS  OF  THE  BONES  OF  THE  FOREARM 


latenilly  of  the  lower  end  of  the  uhia,  the  disappcaranee  of  the 
iihiar  licad  from  the  dorsum  of  the  wrist,  are  to  be  noted.  Be- 
cause  of   the   displacement    of   the   radial   lower   fragment,    the 


Ratlins. 


Line  ol  I'raclure. 


Ulna.  Line  of  fracture. 

Fig.  29S.— Simple  transverse  Colles' fracture.     Lateral  view.     Same  as  figure  295  (Massachu- 
setts General  Hospital). 


)        ^, 


Styloid  process. 


Fig.  299. — Colles'  fracture.     Fracture  of   styloid  of   ulna.     A  T-fiacture  into  the  wrist-joint. 
Much  lateral  deformity  (X-ray  tracing). 


normal  relations  are  no  longer  maintained  between  the  styloid 
processes  of  the  radius  and  ulna.  There  is  a  reversal  of  relations. 
The  radial  styloid  is  higher  than  usual.  It  is  on  the  same  level 
with  or  higher  than  the  head  of  the  ulna. 


COLLES'    FRACTURE — DlFFERENTlMv    DIAGNOSIS 


■39 


It  is  possible  to  have  present  a  fracture  of  the  lower  end  of  the 
radius  (a  Colles'  fracture)  without  any  appreciable  alteration 
in  the  levels  of  the  styloid  processes.  The  existence  of  the 
normal  relations  of  the  styloids  does  not  preclude  the  presence 
of  a  fracture. 

Direct  pressure  over  the  broken  bones  elicits  pain,  but  crepitus 
is  often  undetected  until  the  patient  is  examined  with  the  aid  of 
an  anesthetic.     A  transverse  ridge  is  sometimes  present  on  the 


Ulna. 


Displaced  styloid  process 
of  ulna. 


Fig.  300.— Colles'  fracture  with  fracture  of  base  of  ulnar  styloid  ;  outward  displace- 
ment of  styloid  fragment.  Shaft  of  radius  driven  into  the  lower  fragment  (Massachusetts 
General  Hospital,  1173.     X-ray  tracing). 


Fig.   301.— Radial   fracture   upward   and   outward   (Massachusetts    General    Hospital,    1126. 

X-ray  tracing) . 


posterior  and  external  surface  of  the  radius,  corresponding  to  the 
line  of  fracture.  In  certain  cases  of  Colles'  fracture  the  wrist 
may  not  appear  very  unnatural.  There  may  be  scarcely  any 
deformity.  The  normal  relation  may  be  nearly  preserved.  If 
there  is  little  displacement  of  the  fragments,  it  may  be  difficult 
to  determine  the  existence  of  fracture.  An  appreciation  of 
slight  differences  from  the  normal  will,  under  these  circumstances, 
prove  of  great  value.  The  Rontgen  ray  will  be  of  service  in 
this  connection. 


>40 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


After  injury  to  the  wrist  one  must  consider  in  the  differential 
diagnosis — 

A  sprain  of  the  wrist,  Fracture  of  tlie  shaft  of  one  or  both  l)ones 

Contusion  of  the  bones  near  the  wrist,  low  down, 

Dislocation  of  the  wrist  backward.  Separation  of  the  lower  radial  epiphysis. 

A  Sprain  of  the   wrist   is  rather  unusual.     There   very  often 
exists  in  so-called  sprains  a  definite  anatomical  lesion  of  bone. 


Fig.  302. — Fracture  of  inner  edge  of  the  radius  (X-ray  tracing). 


Fig- 303- — Fracture  of  radial  styloid  (Massachusetts  General  Hospital,  1252.     X-ray  tracing). 


The  deformity  due  to  the  distention  of  the  synovial  sac  with 
fluid  is  conspicuous  over  the  back  of  the  wrist-joint  and,  there- 
fore, near  the  hand.  There  is  tenderness  upon  pressure  over 
the  synovial  membrane  anteroposteriorly.  There  is  little  or  no 
tenderness   over   the   radius   upon   deep   pressure.     There   is   an 


COLLINS'    FRACTURK — DlFF^ERENTlAIv    DIAGNOSIS  241 

absence  of  the  positive  signs  of  fracture.  It  is  not  an  uncommon 
experience  to  find  an  injury  to  the  lower  end  of  the  radius  pre- 
senting no  positive  fracture  signs,  which  is  proved  by  the  Rontgen 
ray  to  be  a  break  of  the  lower  end  of  the  radius.  A  lesion  some- 
what resembling  that  shown  in  figure  292,  the  bone  being  cracked 
along  those  same  lines  but  without  displacement,  is  sometimes 


Fig.  304. — Fracture  of  both  bones  near  wrist.     Note  deformitj'  away  from  (above)  wrist-joint 

(after  Helferich). 


Fig.  305. — Fracture  of  the  lower  end  of  the  radius.    Lateral  view.    Note  silver-fork  deform- 
ity.   Deformity  (above)  near  wrist-joint  (after  Helferich). 


found  to  exist.  Many  of  these  obscure  lesions  are  passed  over 
as  sprains  of  the  wrist.  Any  injury  to  the  wrist,  no  matter  how 
trivial,  should  be  regarded  with  suspicion  until  there  is  absolute 
proof  that  fracture  is  absent. 

A  Contusion  of  One  or  Both  Bones  near  the  Wrist-joint :  Tender- 
16 


242 


FRACTURES    OF    Till;    BOXICS    OF    TIIH    FOKI-ARM 


ness  is  localized.      iMactiirc  signs  are  all  al)scnt.      The  Rcnitgen 
ra\-   will   assist    in   (leterniining  this  diagnosis. 

Dislocation  of  the  wrist  backward  is  rare.  The  posterior 
prominence  is  lower  down  on  the  wrist  than  in  Colles'  fracture. 
The    up])er    snrface    of    the   displaced    carpus   can    be    felt.      The 


/ 


Radial  epiphysis,  oute 
fragment. 


'-^.SmL 


Radial  epipliysis,  inner 

fragment. 
Displaced   styloid   pro- 
cess of  ulna. 
Ulnar  epiphyseal  line. 


Fig.  306. — Fracture  of  the  epiphysis  of  the  lower  end  of  the  radius  and  of  the  styloid  process 
of  ulna  (Massachusetts  General  Hospital,  712.     X-ray  tracing). 


Fig.  307. — Colles'  fracture,  with  fracture  at  lower  end  of  ulna  (X-ray  tracing). 


relation  of  the  two  styloids  is  preserved.  The  deformity  dis- 
appears and  does  not  tend  to  reappear  when  traction  is  made 
on  the  hand  and  pressure  is  made  over  the  dorsal  prominence. 
Fracture  of  the  shaft  (see  Fig.  307)  of  one  or  both  bones  low 
down    may    simulate    the    anteroposterior    deformity    of    Colles' 


Fig.  308. — Case :  Adult.     Very  great  comminution  of   lower  end  of   the  radius.     Extremely 
difficult  to  mold  fragments  into  good  positions.     Note  abduction  of  hand. 


243 


244 


FRACTl'RES    OF    Till':    HoXES    oF    TIIH    FOREARM 


fracture,  but  an  absence  of  other  positive  signs  is  important. 
The  Rontgcn  ray  determines  the  exact  seat  of  the  lesion.  Ab- 
normal mobility  and  crepitus  are  readily  obtained  without  the 
administration  of  an  anesthetic. 

A   Separation    of   the    Lower    Epiphysis    of    the    Radius:    The 
lower  epiphysis  of  the   radius  unites  with  the  shaft   about  the 


Fig.  309. — Dorsal  dislocation  of  the  wrist.     Note  deformity  at  wrist-joint  neither  above  nor 
below  it  (after  Helferich). 


Fig.  310. — Dorsal  dislocation  of  the  hand  at  carpometacarpal  joints.     Note  deformity  below 
wrist  (after  Helferich). 


twentieth  year.  The  radius  increases  in  length  chiefly  through 
growth  from  its  lower  epiphysis.  This  lesion  occurs  much  more 
commonly  than  has  hitherto  been  supposed.  It  is  usually  classed 
as  a  Colles'  fracture,  no  very  careful  examination  being  made. 
The  displacement  of  the  epiphysis  is  backward,  but  it  is  not 
sufficient  to  carry  the  fragment  off  and  out  of  contact  with  the 


COLIvES'    FRACTURE — ASSOCIATED    LESIONS 


245 


diaphysis.  In  Colles'  fracture  the  dorsal  swelling  is  most  in 
evidence.  In  a  separation  of  the  lower  radial  epiphysis  the 
palmar  swelling  is  greatest.  The  lateral  deformity  of  the  wrist 
is  usually  absent  in  epiphyseal  separations.  There  is  often 
less  deformity  than  is  found  in  most  Colics'  fractures,  and  it  is 
nearer  the  hand.     The  crepitus  is   soft   and  cartilaginous,    and 


Fig.  311. — Reduction  of  Colles'  fracture.     Note  position  of  hands  in  forcibly  hyperextending 
the  lower  fragment ;  breaking  up  impaction. 


Fig.  312. — Reduction  of  Colles'  fracture.     Note  grasp  upon  forearm  and  the  lower  fragment  of 
the  radius,  traction  and  countertraction  being  made;  breaking  up  the  impaction. 


easily  obtained  without  an  anesthetic.  Pain  is  present  as  well 
as  tenderness  to  pressure  over  the  epiphyseal  line.  There  is 
often  swelling  along  the  dorsum  of  the  wrist  corresponding  to 
the  area  of  detached  periosteum.  Union  is  rapid  and  complete. 
There  is  almost  never  any  arrest  of  growth  following  this  injury. 
The   treatment   of   separation   of  the   lower   radial   epiphysis   is 


246       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

similar  to  that  of  a  Colles'  fracture.  A  fracture  of  the  lower 
radial  epiphysis  is  occasionally  seen;  it  is,  however,  a  rare  lesion 
(see  Fig.  306). 

Associated  with  every  Colles'  fracture  there  mav  be  one  or 
more  of  the  following  lesions:  A  fracture  through  the  lower  end 
of  the  ulna,  which  is  rather  rare  (see  Fig.  307).  A  fracture 
of  the  styloid  process  of  the  ulna,  which  occurs  in  about  fifty 
to  sixty-five  per  cent,  of  all  cases  (see  Fig.  300).  A  rupture  of 
the  interarticular  triangular  fibrocartilage  at  its  insertion  into 
the  base  of  the  styloid  process  of  the  ulna.  This  is  probably  quite 
common,  and  accounts  in  part  for  the  broadening  of  the  wrist- 
joint.     A  perforation  of  the  skin  by  the  lower  end  of  either  the 


Fig.  313. — Reduction  of  Colles'  fracture.  Note  position  of  the  thumbs  and  fingers. 
Lower  fragment  is  pushed  into  place  while  counterpressure  is  made  by  the  fingers  upon  the 
upper  fragment. 


ulna  or  the  shaft  of  the  radius,  making  an  open  fracture.  A 
fracture  of  the  scaphoid  bone,  although  occurring  often  alone, 
is  not  very  uncommonly  associated  with  Colles'  fracture.  A 
sprain  of  the  hand,  wrist,  forearm,  elbow,  or  shoulder  may  occur. 
It  is  wise  to  examine  the  whole  upper  extremity,  particularly 
a  few  days  after  the  accident,  as  it  is  at  this  time  that  sprains 
associated  with  fracture  are  likely  to  be  detected. 

Treatment. — The  ordinary  uncomplicated  fracture  is  here 
under  consideration.  Reduction  should  be  accomplished  as 
soon  as  possible.  Complete  reduction  can  not  be  made  satis- 
factorily without  the  administration  of  an  anesthetic,  either 
to  complete  or  partial  anesthesia.  Very  great  force  is  needed 
to   accomplish   satisfactory   reduction   of   impacted   fractures   of 


COLLES'  FRACTURE — TREATMENT 


247 


the  radius.  It  is  because  of  the  use  of  too  httle  force  that  often 
a  slight  bony  deformity  remains  after  union  has  taken  place. 
A  Method  of  Reduction. — Grasp  with  the  thumbs  and  fore- 
fingers of  the  two  hands  the  upper  and  lower  fragments.  Free 
the  lower  fragment  completely  from  the  upper  by  pressure  and 


Fig.  314. — Fracture  of  radius  near  wrist.     Method  of  applying  the  posterior  splint  and  dorsal 
pad  in  displacement  of  lower  fragment  backward. 


Fig.  315. — Fracture  of  radius  near  wrist.  Method  of  applying  anterior  splint  and  pad 
and  of  holding  the  two  splints  and  arm  for  the  application  of  straps.  Anterior  splint  is  cut 
out  below  the  thenar  eminence. 


traction  backward  and  forward  and  laterally  upon  the  lower 
fragment,  using  all  the  force  that  is  needed  (see  Figs.  311,  312). 
The  lower  fragment  may  then  be  forced  into  position  by  pressure 
of  the  two  thumbs  upon  the  dorsum  of  the  wrist  (see  Fig.  313). 
When  reduction  is  completed,  the  hand  should  be  allowed  to  rest 


248 


FRACTl'RHS  OF  THE  BONES  OF  THE  FOREARM 


naturalh'  willioul  support  to  ck-tcrniine  whether  there  is  a  re- 
currence of  the  deformity.  If  there  is  no  recurrence  of  the 
deformity,  the  fracture  may  be  fixed.  If  there  is  recurrence  of 
the  deformity,  notice  should  be  taken  of  the  direction  of  the 
displacement  of  the  lower  fragment,  that  proper  pads  may  be 
applied  to  hold  it  in  position.  A  pad  of  compress  cloth  placed 
on  the  dorsum  of  the  wrist  over  the  lower  fragment  will  easily 


^P'^^BF^H 

^L 

1  .  ^i^i^gjm^ii^ 

Fig.  316. — Fracture  of  the  forearm  near  the  wrist-joint.  Anterior  and  posterior  splints. 
Straps  are  taut.  Note  length  of  splints,  the  position  of  the  three  straps,  and  the  cutting  out 
of  the  anterior  splint  to  clear  the  thenar  eminence. 


Fig.  317. — Fracture  of  the  forearm  near  the  wrist-joint.  Notice  wrinkles  in  the  straps. 
The  straps  are  loose  from  the  pressure  of  the  two  splints  together.  Thus  is  illustrated  the 
fact  that  the  straps  should  retain  splints  in  position  without  exerting  much  pressure. 


hold  it  if  ordinarily  displaced.  A  knowledge  of  the  direction 
of  the  displacement  of  the  lower  fragment  will  suggest  the  pre- 
vention of  the  recurrence  of  the  deformity.  The  Rontgen  ray 
is  making  possible  a  more  intelligent  treatment  of  this  fracture 
of  the  radius.  The  bone  is  so  nearly  subcutaneous  that  one 
can  take  advantage  of  an  accurate  knowledge  of  the  line  or  lines 
of   fracture    in    attempting    reduction    of    the    malposition.     In- 


COLLES'  FRACTURE — TREATMENT 


249 


telligently  applied  force  can  now  be  used  in  each  fracture  instead 
of  the  hitherto  bHnd  routine  manipulation.  Thus,  less  injury 
is  done  in  setting  the  fracture,  and  better  anatomical  results 
are  obtained. 


Fig.  318.— Posterior  splint  padded  with  two  thicknesses  of   slieet  wadding.     Two   straps. 
Note  length  of  splint  and  position  of  straps. 


Fig.  319. — Posterior  splint,  three  straps,  and  pad  at  the  seat  of  fracture.     Note  comfortable 
position  of  forearm  and  hand. 


Fig.  320. — Completed  dressing,  similar  to  figures  318,  319.     The  bandage  is  applied  evenly 

and  uniformly. 


It  is  well  to  restore,  if  possible,  the  prominence  of  the  lower 
end  of  the  ulna  at  the  back  of  the  wrist.  Usually,  after  a  Colles' 
fracture  has  healed  and  functional  usefulness  exists  in  the  wrist 
and  hand,  the  ulna  will  be  found  to  have  slumped  forward — to 
have  disappeared  from  the  dorsum  of  the  wrist.     This  can  be 


250       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

prevented  partially  at  the  time  of  setting  the  fracture,  by  padding 
the  ulna  anteriorly  and  by  completely  correcting  the  radial 
deformity  and  strongly  adducting  the  hand. 

RctcniiTc  Apparatus. — The  simplest  splint  is  the  best.  If  there 
is  considerable  swelling  about  the  seat  of  fracture  in  a  rather 
muscular  and  large  arm,  it  is  best  to  use  the  following  apparatus : 
Two  pieces  of  splint-wood,  one  for  the  back  and  the  other  for 
the  front  of  the  forearm,  are  provided.  The  back  or  posterior 
splint  should  extend  from  the  heads  of  the  metacarpal  bones  to 
a  little  above  the  middle  of  the  forearm  (see  Fig.  314).  The 
front  or  anterior  splint  should  extend  from  the  heads  of  the 
metacarpal  bones  to  a  little  above  the  middle  of  the  forearm 
(see  Fig.  315).     These  splints  are  padded  evenly  and  smoothly 


Fig.  321. — Hand  and  fingers  extended.  Dorsal  surface  of  forearm  and  hand  practically 
straight  and  in  the  same  plane.  The  anterior  surface  of  the  forearm  and  hand  are  rounded 
and  irregular  surfaces. 


with  sheet  wadding,  retentive  pads  at  the  seat  of  the  fracture 
being  used  as  needed.  The  hand  and  forearm  are  held  in  semi- 
pronation.  The  hand  is  adducted.  The  dorsal  splint  is  applied 
and  held  in  position.  The  anterior  splint  is  then  applied  with 
the  pads,  and  all  are  held  in  position  by  adhesive-plaster  straps. 
The  arm  and  splints  are  covered  with  a  bandage.  Direct  pressure 
should  be  avoided  over  the  head  and  styloid  process  of  the  ulna 
posteriorly,  in  order  to  minimize  the  disappearance  of  the  bone 
from  the  dorsum  of  the  wrist.  A  pad  placed  anteriorly  and 
laterally  over  the  lower  end  of  the  ulna  is  often  useful  in  reducing 
the  ulnar  head  and  styloid.  The  adhesive-plaster  straps  should 
be  snugly  but  loosely  applied.  They  are  intended  simply  to 
retain   the   splints   in   position    (see   Fig.    316).     After  their  ap- 


coixES'  fracture; — treatment 


251 


plication,  pressing  the  two  splints  together  should  show  that 
there  is  considerable  slack  in  the  straps  (see  Fig.  31 7j;  a  springi- 
ness should  exist  between  the  splints.  The  necessary  pressure 
on  the  splints  should  be  secured  by  the  bandage.  The  fingers 
are  allowed  to  be  free  and  movable.  The  arm  is  held  in  a  sling. 
The  sling  should  be  so  adjusted  as  to  receive  the  whole  weight 
of  the  arm,  the  hand  lying  free  from  the  upward  pressure  of  the 
sling.  The  sling  should  be  applied  with  the  ends  crossed  in 
front  of  the  neck. 

At  the  end  of  the  first  week  in  most  cases,  in  place  of  the  two 
anteroposterior  splints,  it  will  be  wise  to  use  one  posterior  splint 
only  and  an  anterior  pad  over  the  seat  of  fracture.  The  pos- 
terior splint  is  applied  evenly  padded,  and  if  necessary,  a  small 
pad  is  placed  over  the  dorsum  of  the  lower  fragment.  The 
splint  is  held  in  place  by  two  adhesive-plaster  straps — one  at  the 


Fig.  322. — Anterior  and  posterior  splints.    Diagram  of  pad  to  fit  the  radial  arch. 


upper  end  of  the  splint  around  the  forearm,  the  other  around 
the  metacarpal  bones  at  the  lower  end  of  the  splint  (see  Fig. 
318).  The  fracture  should  be  held  securely  by  a  third  strip  of 
adhesive  plaster  at  the  seat  of  fracture  over  a  compress-cloth 
pad,  which  fills  up  the  anterior  hollow  of  the  radius  (see  Figs. 
319,  322).  This  pad  holds  the  fragments  securely  A  roller 
bandage  gives  even  compression  and  support  to  the  whole  arm 
(see  Fig.  320). 

The  posterior  surfaces  of  the  forearm,  wrist,  and  hand  in  the 
extended  position  are  practically  in  one  plane  (see  Fig.  321); 
hence,  the  reasonableness  of  the  use  of  the  posterior  splint.  The 
arm  lies  naturally  upon  it.  The  anterior  surface  only  requires 
accurate  padding.  The  difficulty  in  applying  an  anterior  splint 
accurately  to  the  forearm  and  wrist  is  rendered  clear  by  the 
illustration.     The  front  of  the  forearm  and  wrist  is  a  rounded 


25- 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


and  uneven  surface  (see  Fig.  321).  In  order  accurately  to  control 
the  bone  bv  a  splint  applied  to  the  anterior  surface  of  the  fore- 
arm, the  padding  must  be  applied  with  greater  care  than  is  or- 
dinarily exercised.  No  splint  is  manufactured  that  fits  the  wrist 
accurately.  If  the  surgeon  depends  upon  manufactured  and 
molded  splints,  he  is  in  very  great  danger  of  neglecting  the  frac- 
ture. It  is  best  for  the  surgeon  to  use  simple  splints,  and  to 
hold  the  fracture  reduced  by  personally  applied  pads  and  straps. 


Fig.  323. — Colles'  fracture.     Position  of  short  dorsal  splint  of  wood  and  palmar  pad  of  com- 
press cloth.     Note  method  of  holding  before  the  application  of  the  strap. 


Fig.  324. — Colles'  fracture.     Short  dorsal  splint  and  palmar  pad  held  in  position  by  adhesive- 
plaster  strap. 


Until  the  time  of  union  the  arm  should  always  be  comfort- 
able. The  patient  should  be  seen,  if  convenient,  within  the  first 
twenty-four  hours  of  the  application  of  the  splint.  Swelling 
may  occur  after  the  splints  are  applied,  causing  blueness  or 
swelling  of  the  fingers.  The  bandage  may  need  reapplying  to 
relieve  this  increase  of  pressure.  With  the  subsidence  of  the 
primary  swelling  the  bandage  naturally  loosens  and  will  require 
tightening.     It  is  rare   that  the  straps  and   padding  will  need 


COLLES'    FRACTURE — TRRATMIvNT 


253 


more  than  slight  readjustment  during  the  first  week  of  treatment. 
At  least  every  three  days  the  pads  should  be  removed  with  great 
care,  and  the  arm  carefully  inspected.  The  alinement  of  the 
fragments  is  maintained  by  readjustment  of  the  pads. 


Fig.  325. — Colles'  fracture.  Cravat 
sling  holding  wrist  improperly.  Hand 
pronated. 


Fig.  326. — Colles'  fracture.  Cravat 
sling  holding  wrist  properly.  Hand  semi- 
supinated.  Wrist  resting  upon  ulnar  side 
with  hand  unsupported. 


Fig.  327. — Right  Colles'  fracture  in  an  old  woman.  Splints  applied  for  five  weeks  with- 
out removal.  Note  deformity  and  flattening  of  hand  and  forearm.  The  fingers  and  wrist 
are  stiff  and  swollen.     Left  hand  is  normal. 


Gentle  massage  should  be  instituted  to  the  fingers,  hand,  wrist, 
and  forearm  during  the  second  week.  Passive  and  active  move- 
ments of  the  fingers  and  wrist  are  to  be  made  through  the  second 


254  FRACTIRKS    oK    THE    BOXES    OF    THE    FOREARM 

week.  During  the  second  or  third  week  it  will  be  possible  to 
shorten  the  dorsal  splint  and  also  to  increase  the  amount  of  passive 
and  active  motion.  At  the  end  of  the  second  or  third  week 
the  union  will  be  found  to  be  firm.  During  the  third  or  fourth 
week  the  splint  may  be  removed  and  the  wrist  be  supported  by  a 
wooden  dorsal  pad  (see  Figs.  323,  324)  two  inches  long  and  the 
width  of  the  wrist,  and  by  a  palmar  radial  pad  of  compress  cloth 
and  strips  of  adhesive  plaster  about  two  inches  wdde.  The 
middle  of  the  plaster  should  come  at  the  line  of  the  break  in  the 
bone.  After  the  fourth  week  all  padding  may  be  removed,  and 
the  wrist  supported  by  a  simple  bandage.  The  fingers  and 
hand  may  be  used  at  this  time.  After  the  removal  of  the  splint 
and  while  the  arm  is  carried  in  a  sling  great  care  must  be  ex- 
ercised lest  lateral  deformity  result  through  an  improper  adjust- 
ment of  the  sling  (see  Fig.  325).  The  forearm  should  rest  in  the 
sling  upon  the  ulnar  side,  and  the  hand,  being  unsupported,  should 
be  slightly  adducted  (see  Fig.  326). 

The  treatment  of  a  "reversed  Colles'  "  fracture  (see  Fig.  284) 
will  differ  from  the  treatment  of  the  ordinary  fracture  only  in 
the  method  of  reduction  and  in  the  position  of  the  retaining  pads. 
An  anterior  (palmar)  pad  will  be  needed  over  the  lower  frag- 
ment and  a  posterior  (dorsal)  pad  over  the  shaft  of  the  radius. 

Prognosis  and  Result. — The  swelling  about  the  fracture  in 
elderly  people  will  persist  longer  than  in  the  young.  A  func- 
tionally useful  wrist-joint  and  hand  should  follow  a  simple  un- 
complicated Colles'  fracture  in  healthy  young  adults.  For 
some  weeks  tenderness  mav  exist  over  the  styloid  of  the  ulna. 
Limitation  of  pronation  and  supination  may  persist  for  some 
time,  disappearing,  after  several  months,  more  or  less  com- 
pletely. Supination  is  the  last  movement  to  be  recovered. 
Limitation  of  movement  at  the  wrist  and  in  the  fingers  is  not 
incompatible  with  a  useful  wrist-joint.  Bony  union  is  rapid — 
within  three  weeks.  Care  must  be  exercised  lest  in  the  early 
removal  of  support  the  soft  callus  is  molded,  by  the  ordinary 
movements  of  the  wrists  and  hand,  into  some  permanent  de- 
formity. 

It  is  not  uncommon  for  the  line  of  the  fracture  of  the  lower 
end  of  the  radius  to  extend  into  and  involve  the  sigmoid  cavity 


COIvLES'    FRACTURD — PROGNOSIS  255 

of  the  radius.  Thus  the  inferior  radio-uhiar  joint  is  involved 
in  the  fracture.  This  fact  is  of  importance,  as  it  helps  to  explain 
the  limitation  of  motion  in  pronation  and  supination  which  so 
often  exists  after  fracture  of  the  lower  end  of  the  radius.  Often 
perfect  supination  is  the  last  movement  to  be  recovered,  and 
this  may  in  part  be  explained  by  the  involvement  of  the  inferior 
radio-ulnar  joint. 

The  destruction  of  parts  of  the  lower  fragment  of  the  radius 
may  have  been  so  complete  that  it  is  impossible  to  restore 
the  wrist  to  its  normal  shape,  and  some  bony  deformity  will 
remain  permanently  (see  Fig.  308).  Bony  deformity  is  not  in- 
compatible with  a  functionally  useful  arm.  In  many  instances 
it  is  impossible  wholly  to  prevent  a  slumping  forward  of  the 
head  of  the  ulna  and  its  corresponding  disappearance  from  the 
back  of  the  wrist.  Complete  reduction  of  the  radial  deformity 
together  with  a  frequently  re-adjusted  pad  upon  the  palmar 
surface  of  the  wrist  over  the  slumping  ulna-head  are  the  best 
methods  for  preventing  the  disappearance  of  the  ulna  from  the 
dorsum  of  the  wrist.  Some  slight  widening  of  the  wrist  will 
remain  after  most  Colles'  fractures.  The  changes  in  the  tendon 
sheaths  about  the  fracture,  the  periarticular  adhesions  that  form, 
especially  in  elderly  people,  cause  much  more  hindrance  to  re- 
covery of  function  than  do  the  bony  alterations  (see  Fig.  327). 
Early  and  persistent  massage  and  passive  motion  will  prevent 
these  changes  from  becoming  permanently  troublesome.  Old 
people  are  liable  to  have  considerable  difficulty  in  regaining  the 
movements  of  the  fingers,  on  account  of  adhesions  within  and 
without  the  tendon  sheaths.  The  continued  use  of  the  hot-air 
treatment  is  of  value  in  restoring  mobility  to  the  wrist  and  fingers. 

Colles'  fractures  that  have  bony  union  with  marked  deform- 
ity should  be  corrected  by  osteotomy,  if  the  wrist  is  function- 
ally impaired.  Colles'  fractures  two  or  three  weeks  old  may 
be  refractured  manually,  if  necessary,  to  correct  existing  deform- 
ity. The  ease  of  refracture  and  the  limits  in  time  wdthin  w^hich 
it  is  possible  will  vary  with  individual  cases.  The  more  nearly 
the  deformity  in  Colles'  fracture  is  corrected  at  the  first  setting, 
the  milder  will  be  the  subsequent  pain  about  the  wrist. 


CHAPTER  XI 

FRACTURES  OF  THE  CARPUS,  METACARPUS,  AND 

PHALANGES 

FRACTURE  OF  THE  CARPUS 
Simple  fracture  of  the  carpal  bones  is  unusual.  It  is  associated 
with  other  injuries.  It  is  not  uncommonly  seen  in  crushes  re- 
sulting in  open  fracture.  The  scaphoid  is  found  fractured  in 
certain  Colics'  fractures  and  in  falls  upon  the  outstretched  hand. 
There  are  many  cases  of  painful  wrist,  "rheumatism"  about  the 


Fig.  328. — Normal  wrist  (X-ray  tracing). 

wrist,  weak  wrist,  and  sprained  wrist  that  are  instances  of  un- 
recognized fracture  of  the  scaphoid  bone.  The  persistence  of 
the  difficulty  necessitates  a  physician's  examination.  In  these 
cases  a  Rontgen-ray  examination  will  reveal  the  true  nature  of 
the  lesion.  In  interpreting  X-rays  of  the  carpus  following 
injury  it  must  not  be  overlooked,  as  Prof.  Thomas  D wight  has 

256 


fracture;  of  the  carpus 


257 


observed,  that  in  about  i  per  cent,  of  all  subjects  the  scaphoid 
is  divided  into  two  parts  in  the  course  of  its  development.  vSuch 
an  anomaly  might  be  easily  mistaken  for  a  fracture  of  the  scaph- 
oid if  the  appearances  in  the  X-ray  alone  were  depended  upon. 
After  fracture  of  the  scaphoid  bone  persistent,  painful  limitation 


Fig.  329.— Case  :  Fracture  of  the  scaphoid  and  fissure  of  radius  (X-ray  tracing)  (Balch). 


Crack  of  ulna. 


Epiphyseal  line. L 


Scaphoid  fragment. 
Scaphoid  fragment. 


Epiphyseal    line  of 
radius. 


Fig.  330.— Fracture  of  the  scaphoid.     Lesion  of  epiphysis  of  ulna  (X-ray  tracing)  (Balch). 


of  extension  at  the  wrist  is  hot  at  all  uncommon.     The  os  magnum 
is  sometimes  fractured  by  falls  upon  the  hand. 

Treatment. — If    there    is    displacement,    immediate    pressure 
and  counterpressure,  associated  with  extension  and  flexion  of  the 
wrist-joint,  under  an  anesthetic  will  usually  reduce  the  displace- 
ment.    Immobilization  of  the  wrist-joint  should  be  secured  by 
17 


258       FRACTURES  OF  CARPUS,  METACARPUS.  AND  PHALANGES 

means  of  a  dorsal  splint  extending  from  above  the  middle  of  the 
forearm  to  the  heads  of  the  metacarpal  bones  (see  Fig.  318). 
It  should  be  retained  by  two  adhesive-plaster  straps.  Sheet 
wadding  and  gauze  roller  bandages  are  then  carefully  applied 
to  the  arm  the  whole  length  of  the  splint  (see  Fig.  320). 


Fig.  331. — Fracture  of  the  scaphoid.    The  two  fragments  are  seen  near  the  styloid  of  the 
radius  (X-ray  tracing)  (Balch). 


I,'-^^J 


Scaphoid  fragment 

Scaphoid  fragment. \_ 

\ 
\ 


Fig.  332. — Case  :  Fracture  of  the  scaphoid  (X-ray  tracing). 


With  the  splint  in  position  gentle  massage  to  the  wrist  and 
forearm  after  the  first  week  will  hasten  healing.  Gentle  passive 
motion  with  more  vigorous  massage  will  be  indicated  at  the  end 
of  two  weeks.     At  the  end  of  three  or  four  weeks  all  support  save 


FRACTURE   OF    THE;    MKTACARPAI.    liONUS 


259 


a  roller  bandage  may  be  omitted.  vStiffness  will  persist  after 
this  injury,  especially  in  elderly  people  (see  Figs.  328-332  in- 
clusive). 


FRACTURE  OF  THE  METACARPAL  BONES 

The  third  and  fourth  metacarpal  bones  are  the  ones  most  com- 
monly broken.     The  fracture  is  due  to  a  blow  upon  the  knuckles. 

Symptoms. — The  deformity  is  characteristic.  The  very  con- 
siderable swelling  often  obscures  the  outline  of  the  bones,  but 
palpation  detects  the  lower  end  of  the  upper  fragment  in  the 
dorsum  of  the  hand,  while  the  upper  end  of  the  lower  fragment 
is  sometimes  felt  in  the  palm  of  the  hand 
(see  Fig.  333).  This  deformity  is  charac- 
terized by  a  loss  from  the  line  of  the 
knuckles  of  that  knuckle  corresponding  to 
the  fractured  metacarpal  (see  Figs.  334, 
335).  Pain  and  crepitus  are  present.  The 
hand  can  not  be  closed  tightly  on  account 
of  the  swelling  and  pain. 

To  obtain  crepitus  easily  and  to  assist  in 
reducing  the  fracture,  it  is  best  to  grasp 
the  finger  corresponding  to  the  fractured 
metacarpal  with  the  whole  right  hand, 
steadying  the  injured  metacarpus  with  the 
left  hand,  and  then  to  make  steady  and 
continuous  traction  (see  Fig.  335).  The 
distal  fragment  is  so  short  and  movable 
that  unless  this  method  is  used  to  steady 
the  fragment  it  will  be  difficult  to  deter- 
mine crepitus  and  to  reduce  the  fracture. 
This  fracture  heals  readily.  Occasionally,  however,  a  suppura- 
tive process  may  complicate  recovery  even  when  the  fracture  is 
not  an  open  one. 

Bennett's  fracture,  commonly  designated  "stave"  of  the 
thumb,  should  be  mentioned  here.  It  is  a  fracture  of  the  prox- 
imal end  of  the  metacarpal  of  the  thumb,  oblique  and  into 
the  joint  with  the  trapezium.  (See  figure  of  X-ray,  No.  343.) 
The   metacarpal   bone   is   displaced   backward.     There   is   great 


Fig.  333. — Fracture  of 
third  metacarpal,  showing 
dropping  of  knuckle.  Liga- 
mentous preparation. 


26o      FRACTl'RES   OF   CARPUS,    MinWCARIMS,    A\I)   rilALANCIilS 

disability    in    opposing    Ihc  lluiinh    and    indcx-fniger.      ("irasping 

small  objects  is  impossible.  Pressure  ujion  the  ball  of  the  thumb 
is  painful. 

The  injuries  likely   to  be  mistaken   for   this   fracture  are  sub- 


^  ig-  334- — A,  Fracture  of  neck  of  fourth  metacarijal  bone.  Swellinj;  of  finger  anil  knuckle. 
Knuckle  has  dropped  downward  toward  the  palm.  B,  Normal  hand.  Line  of  knuckles 
shown.     Contrast  with  A. 


Fig.  335- — Fracture  of  the  fourth  metacarpal  bone.  View  of  two  hands  from  behind  :  A, 
Normal  line  of  knuckles.  B,  Knuckle  of  the  ring-finger  has  dropped  downward.  Deformity 
well  shown. 

luxation  of  this  same  joint,  a  sprain  of  this  joint,  and  a  contusion 
of  this  part. 

Treatment. — After  reducing  the  fracture  by  traction  and 
pressure  as  suggested,  it  must  be  held  in  place  by  special  padding, 
for  the  deformity  tends  to  recur.     The  hand  and  forearm  are 


Fig.  336.- 


-Method  of  grasping  hand  and  finger  in  examining  for  fracture  of  metacarpal  bone, 
and  in  reducing  such  a  fracture. 


Fig.  337. — Fracture  of  the  neck  of  the  second  metacarpal.  Method  of  securing  extension. 
Note  adhesive  plaster,  rubber  tubing,  peg,  padding  to  finger,  pad  over  proximal  fragment. 
Counterextension  by  adhesive  plaster  about  wrist.     Ready  for  the  application  of  a  bandage. 


Fig.  338. — Fracture  of  the  metacarpal  of  the  index-finger.     Use  of  roller  bandage, 
of  roller  bandage.     Method  of  traction  and  countertraction. 
261 


262   FRACTIRES  OF  CARPUS,  METACARPUS,  AND  PHALANGES 

supported  u])()ii  a  properly  padded  ])almar  splint.  A  ])ad  is 
placed  in  the  palm  ()\-er  the  prominent  l()\\er  end  of  the  meta- 
carpal.    Another  pad   is  placed  upon  the  dorsum  of  the   hand 


Fig.  339. — Fracture  of  the  metacarpal  of  the  index-finger.     Completion  of  traction.     Pressure 
and  counterpressure  by  thumb  on  the  dorsum  and  on  bandage  in  the  palm  of  the  hand. 


Fig.  340. — Fracture  of  the  mc-lacaii)al  of  the  iii(lcx-fmt;cr.     Ciniipletion  ni  tlie  a[)plication  of 
the  dressing.     Adhesive-plaster  straps  holding  hand  and  roller  bandage  in  position. 


over  the  upper  fragment.     These  pads  are   secured   by  narrow 
strips   of   adhesive    plaster.     The   whole   is   then   bandaged.     If 


FRACTURE    OF    THE    METACARI'AL    BOiNES 


263 


after  carefully  padding  the  two  fragincnts  and  immobilizing  them 
the  deformity  is  reproduced,  the  fragments  slipping  by  each 
other,  it  may  be  necessary  to  make  permanent  traction  upon 
the  finger  (see  Fig.  337).  This  is  best  done  by  applying  narrow 
adhesive-plaster  straps  to  the  sides  of  the  finger  held  in  place 
by  circular  and  oblique  straps.  The  hand  rests  upon  the  palmar 
splint.  An  adhesive-plaster  circular  band  passed  about  the 
wrist  and  splint  offers  continuous  countertraction.  If  the  band 
is  carried  between  the  thumb  and  forefinger,  greater  security 
is  obtained,  and  there  is  much  less  likelihood  of  slipping  of  the 


Fig.  341. — Transverse  fracture  of 
the  last  three  metacarpals  (X-ray  trac- 
ing). 


Fig.  342. — Oblique  fracture  of  the  third 
and  fourth  metacarpals  (Massachusetts 
General  Hospital,  1142.     X-ray  tracing). 


plaster.  The  extension  upon  the  finger  is  obtained  by  fastening 
the  extension  strips  to  small  pieces  of  rubber  tubing,  and  carrying 
the  tubing  around  a  wooden  peg  or  screw  passed  through  a  hole 
in  the  splint. 

A  simple  contrivance  for  a  fracture  with  little  displacement 
is  the  use  of  a  roller  bandage  (see  Figs.  338-340  inclusive).  A 
roller  bandage  of  cotton  cloth  that  is  firm  and  not  easily  com- 
pressed and  of  a  size  comfortable  for  the  hand  to  grasp  is  selected. 
This  is  placed  in  the  palm  of  the  extended  hand;  the  fingers 


Proximal  fratrnifm.— 


F'g-  343- — Fracture  of  the  upper  end  of  metacarpal  bone  of  thumb.  Displaced  upper 
fragment  could  be  felt  in  the  palm  of  the  hand  (Massachusetts  General  Hospital,  1785. 
X-ray  tracing). 


Phalangeal  epiphysis. ' 


Normal  epiphyseal  line  — 
and  epiphysis. 


Phalanx. 


■         Separated  epiphysis 
second  metacarpal. 


P'ig.  344. — Separation  of  the  distal  epiphysis  of  the  second  metacarpal  bone.  Displace- 
ment into  the  palm  of  the  hand.  Rare  (Massachusetts  General  Hospital,  1765.  X-ray 
tracing). 


F'g-  345— Fracture  of  terminal  phalanx  of  thumb.     Anteroposterior  and  lateral  views  (X-ray 

tracings). 
264 


FRACTURP:    of    Tlir:    IMIM.ANCKS 


26  = 


and  metacarpal  heads  are  drawn  down  firmly  over  it.  This 
position  is  maintained  by  a  broad  strip  of  adhesive  plaster  around 
the  whole  hand.  Pads,  as  with  the  palmar  splint,  may  be  used 
to  reinforce  the  roller  bandage.  Unless  great  care  is  exercised, 
this  method  will  result  in  posterior  bowing  of  the  metacarpal 
bone.  If  there  is  an  anterior  displacement  of  either  or  both 
fragments,  this  roller-bandage  apparatus  is  very  efficient  in 
maintaining  reduction  of  the  deformity. 


Fig.  346.  —  Fracture  of  the  finger. 
Wooden  splint  applied  to  the  palmar  sur- 
face.    Note  straps  and  length  of  splint. 


Fig.   347. — Finger    splint    of    copper  wire 
applied. 


This  apparatus  should  be  carefully  inspected  each  day  during 
the  first  week,  to  be  sure  that  the  position  obtained  is  held  firmly. 
After  three  weeks  the  splint  may  be  omitted.  Massage  during 
the  third  week  will  be  of  benefit.  Great  care  must  be  exercised 
in  the  use  of  the  hand  following  the  removal  of  the  splint  until 
the  fourth  week  is  passed,  for  deformity  may  result  (see  Figs. 
341-344  inclusive). 


FRACTURE  OF  THE  PHALANGES 

The    bones    lie    subcutaneously ;    fractures    of    the    phalanges 
are,  accordingly,  comparatively  easy  to  detect.     Fractures  near 


Fig.  348. 


-A,  Finger  splint  applied  to  middle  finger,  three  straps.     Note  position  of  splint  in 
palm  of  hand.     B,  Finger  splint  of  aluminium  or  tin,  anterior  surface. 


Fig.  349. — Palmar  wooden  thumb  splint.     Note  shape,  pads,  straps,  i)osition. 

266 


fracture;  of  the  phalanges 


267 


the  articular  surfaces  are  hard  to  detect  because  joint  crepitus 
is  deceptive.  The  so-called  base-ball  finger  may,  in  many  in- 
stances, be  associated  with  a  fracture  of  the  head  of  the  meta- 
carpal bone,  and,  involving  the  joint,  occasion  a  slow  conva- 
lescence (see  Fig.  333). 

Symptoms. — Crepitus,  pain,  and  abnormal  mobility  are  pres- 
ent, and  occasionally  deformity  is  seen. 

Treatment. — It  is  important  that  the  alinement  of  the  phalanx 
be  maintained.  Rotation  of  the  lower  fragment  upon  its  long 
axis  is  especially  to  be  guarded  against.  Temporarily,  if  there 
is  much  swelling,   the  broken  finger  may  rest  upon  a  palmar 


Fig.  350.— Lateral  splinl  of  wood  for  fracture  of  the  thumb.     Note  pad  at  the  side  of  first 
phalanx,  to  correct  lateral  deformity. 


splint,  the  two  adjoining  fingers  serving  as  lateral  splints  to 
steady  it.  The  contiguous  skin  surfaces  must  be  protected 
by  strips  of  cotton  cloth  and  a  drying  powder. 

A  single  splint  of  thin  wood,  extending  from  the  middle  of 
the  palm  of  the  hand  to  the  finger-tip,  and  held  in  position  by 
adhesive-plaster  straps,  is  most  useful  (see  Fig.  346).  The 
splint-wood  used  should  be  cut  thin  and  not  left  thick  and  bung- 
ling— half  the  thickness  of  the  wood  of  an  ordinary  cigar  box 
is  about  right.  The  splint  should  be  a  little  narrower  than  the 
finger  itself.     A  narrow  cotton  bandage  applied  over  the  finger 


268   FRACTURES  OF  CARPUS,  METACARPUS,  AND  l'HALAN<;ES. 

or  a  simple  cot  to  cover  the  finger  will  be  coinfortable  and  will 
assist  in  immobilization.  Ordinary  letter-paper,  by  continued 
folding,  mav  be  made  into  a  narrow  and  suitable  splint.  This 
is  simple  and  efficient.  It  should  be  held  in  place  by  a  bandage 
or,  preferably,  bv  a  cot.  Ordinary  copper  wire  may  be  used, 
as  shown  in  the  illustration,  without  any  padding  (see  Fig.  347). 
This  serves  as  a  proper  protection  after  the  first  week  or  two, 
and  is  not  so  clumsy  as  other  splints.  The  aluminium  or  tin 
finger  splint  is  easily  made  and  satisfactory  (see  Fig.  348).  Any 
displacement  in  this  fracture  may  be  easily  adjusted  by  narrow 
adhesive  straps  and  small  pads. 

Fractures   of   the   first   and    second    phalanges   of   the   thumb 


F'g'  351.— Thumb  splint :  a.  Pattern— measurements  are  in  inches;  b,  position  of  splint.    Note 
extension  of  thumb  (after  Goldthwaite). 


may  be  satisfactorily  treated  after  reduction  upon  a  dorsal  or 
lateral  splint  of  wood,  if  proper  padding  is  employed  (see  Figs. 
349,  350).  Frequently,  however,  the  tin  splint  fitted  to  the 
cleft  between  the  thumb  and  forefinger  as  shown  in  the  illustra- 
tion (Fig.  351),  will  immobilize  these  fractures  more  securely 
and  comfortably. 

Open  Fractures  of  the  Phalanges. — These  are  usually  followed 
by  profuse  suppuration  from  necrosis  of  the  fractured  bones. 
This  fracture  is  to  be  treated  with  extreme  care,  especially  as 
regards    antisepsis.     Immobilization    should    continue    at    least 


OPEN  FRACTURES  OF  THE  PHALANGES  269 

four  weeks.  If  at  the  end  of  this  time  union  has  not  occurred, 
the  patient  may  be  given  the  option  of  continuing  the  treatment 
or  of  having  the  finger  amputated.  If  union  does  not  occur 
after  four  weeks  of  careful  treatment,  it  is  highly  improbable 
that  it  will  ever  occur.  Resection  of  the  bones  may  be  attempted 
before  amputation. 


CHAPTER  XII 
FRACTURES  OF  THE  FEMUR 

FRACTURE  OF  THE  HIP  OR  NECK  OF  THE  FEMUR 
Anatomy. — The  crest  of  the  ihum  can  be  felt  throughout  its 
entire  extent,  from  the  anterior  superior  spine  to  the  posterior 
superior  spine.  The  posterior  superior  spine  corresponds  to  the 
level  of  the  center  of  the  sacro-iliac  synchondrosis.  The  great 
trochanter  of  the  femur  is  easily  distinguished  even  in  fat  in- 


Fig-  352.— Nelatoii's  line  (A  D)  from  anterior  superior  spine  of  the  ilium  to  the  tuberosity 
of  the  ischium.  A  C  X,  Bryant's  triangle.  Distance  (X  C)  from  top  of  trochanter  to  perpen- 
dicular (A  B)  dropped  from  anterior  spine  to  horizontal  table  top  is  Bryant's  measurement. 
After  fracture  this  measurement  may  be  less  than  normal. 


dividuals.  Nekton's  line  is  determined  by  stretching  a  tape 
from  the  anterior  superior  spine  of  the  ilium  to  the  tuberosity 
of  the  ischium.  The  top  of  the  great  trochanter  Hes  at  or  a  little 
below  Nelaton's  line,  and  about  opposite  to  the  symphysis  pubis. 
The  internal  condyle  of  the  femur  looks  in  the  same  general 
direction  as  the  head  and  neck  of  the  femur  (see  Figs.  353,  354)- 

270 


I^RACTURE;    of    THH    NIvCK    of    Tllli    FliMlIR 


271 


The  anterior  superior  spine  of  the  ilium  is  of  importance  because 
from  it  measurement  is  made  in  taking  the  length  of  the  legs 
after  fracture  of  the  femur.  Normally,  the  fingers  can  be  hooked 
behind  the  great  trochanter  toward  the  posterior  surface  of  the 
neck  of  the  bone.  By  this  manipulation  the  posterior  portion 
of  the  capsule  of  the  joint  can  be  felt. 


Fig.  353. — Femur,  from  front.  Note 
normal  relation  of  direction  of  head  and 
neck  to  that  of  internal  condyle. 


Fig.  354. — Femur,  from  outer  side. 
Note  normal  anterior  bowing  and  relation 
of  direction  of  head  and  neck  to  that  of  in- 
ternal condyle. 


Fracture  of  the  Neck  of  the  Femur  in  Adults. — This  accident 
occurs  most  frequently  in  elderly  people.  It  ordinarily  is  associ- 
ated with  a  very  slight  injury,  such  as  a  trip  and  fall  upon  the 
floor  from  the  standing  position.  Undoubtedly,  in  many  in- 
stances the  fracture  precedes  the  fall.     It  is  often  difhcult  to 


2  72  FRACTURES    OF    TIIIv    FKMUR 

dctormiiic  the  exact  seat  of  the  lesion.  Whether  the  fracture 
is  within  or  without  the  capsule  of  the  joint  is  of  comparatively 
little  moment,  (hi  the  other  hand,  whether  the  fracture  is 
impacted  or  uninijiacted  is  of  the  (greatest  importance.  Frac- 
tures of  the  base  of  the  neck  of  the  bone — that  is,  fractures  near 
the  trochanter — are  usually  impacted.  Fractures  of  the  neck 
toward  the  head  of  the  bone  are  usually  uninipacted  (see  Fig. 
355).  Impacted  fractures  unite  readily.  Unimpacted  fractures 
often  remain  ununited. 

Symptoms. — The   patient   is  unable   to   rise   from   the   ground. 
A  contusion  mav  be  seen  over  the  hip  as  a  result  of  the  fall.     There 


Fig.  355.— Adult  femur.     Upper  portion  of  shaft  and  head  and  neck.     The  lines  show  the 
usual  seat  of  fracture  of  the  neck  of  the  bone. 

is  pain  in  the  hip  while  the  patient  is  lying  still.  This  pain  is 
increased  upon  motion  at  the  hip.  There  is  inability  to  move 
the  injured  leg  easily  and  painlessly.  There  is  limitation  of 
motion  of  the  injured  leg.  While  lying  upon  the  back  it  is  im- 
possible for  the  patient  to  raise  the  heel  from  the  bed.  The 
foot  is  everted,  the  leg  having  rolled  outward.  The  whole  ex- 
tremity lies  helpless  (see  Fig.  356).  There  is  a  slight  appreciable 
fullness  below  the  fold  of  the  groin.  This  fullness  in  the  outer 
upper  part  of  Scarpa's  triangle  corresponds  to  a  non-depressible 


FRACTURE    OF    THE    HIP — EXAMINATION  273 

area  associated  with  fracture  of  the  neck  of  the  femur.  SHght 
shortening  of  the  leg  exists.  After  three  or  four  days  this  shorten- 
ing may  increase  to  two  inches.  The  trochanter  is  above  Nel- 
aton's  Hne.  The  fascia  above  the  trochanter  is  relaxed  (see 
Fig.  357).  This  is  especially  noted  in  the  standing  position,  with 
the  patient  resting  the  weight  upon  the  well  leg.  If  the  frac- 
ture is  an  impacted  one,  crepitus  will  be  absent  upon  gentle 
manipulation,  unless  the  impaction  has  been  broken  up  by  some 
unwise  means.  If  the  fracture  is  unimpacted,  crepitus  can  be 
detected  by  the  hand  while  traction  or  gentle  rotation  of  the  leg 
is  made.  The  foot  is  everted  whether  impaction  is  present  or 
not.  If  the  impaction  is  of  the  anterior  portion  of  the  neck,  in- 
version will  be  present;  if  the  impaction  is  of  the  posterior  por- 


Fig.  356. — Case  :    Impacted  fracture  of  the  left  hip.     Note  helpless  attitude   of    limb ;  foot 

everted. 


tion  of  the  neck,  eversion  will  be  present  (see  Figs.  358,  359). 
Impacted  eversion  can  not  be  inverted  nor  can  impacted  inversion 
be  everted  without  breaking  up  the  impaction.  In  these  cases 
of  marked  eversion  and  inversion  a  dislocation  of  the  hip  must 
be  excluded  if  possible. 

Examination. — A  prolonged  search  for  crepitus  and  abnormal 
mobility  must  never  be  attempted.  In  order  to  avoid  unneces- 
sary movement  of  the  hip  and  because  inspection  and  gentle 
palpation  alone  will  so  often  decide  the  diagnosis,  it  is  wise  to 
follow  a  routine  examination. 

The  history  of  the  accident  should  be  obtained.  The  presence 
and  location  of  pain  are  determined.  How  much  is  the  func- 
tional usefulness  of  the  leg  involved?  What  does  inspection 
reveal  as  to  the  local  condition  and  the  position  of  the  limb? 


274 


FRACTIRKS    OF    TllH    FKMl'R 


What  docs  palpation  reveal?  How  do  the  measurements  of  the 
leg  and  the  trochanter  compare  with  similar  measurements  of 
the  uninjured  leg?  Last, — and  to  be  avoided  if  a  diagnosis  has 
been  reached.— what  does  gentle  manipulation  show  as  to  the 
presence  of  crepitus  in  the  hip? 

In  order  to  make  a  systematic  examination  all  clothing,  of 
course,  should  be  removed  from  the  patient.  He  then  should 
be  placed  upon  a  firm  and  even  surface.     A  hard  mattress,  a 


Fig.  357. — Relaxation  of  the  fascia  lata  as  a  result  of  fracture  of  the  hip.     Most  obvious  at 
point  shown  by  the  arrow. 


table,  or  a  comforter  spread  upon  the  floor  will  provide  the 
necessary  conditions.  An  anesthetic  is  hardly  ever  necessary 
for  diagnostic  purposes.  If  an  anesthetic  is  employed,  the  hip 
should  be  handled  in  the  gentlest  manner  possible.  With  an 
anesthetic  all  muscular  spasm  is  abolished ;  therefore,  move- 
ments of  the  hip  are  made  without  the  protection  of  volun- 
tary muscular  spasm.  All  sudden  quick  movements  should  be 
avoided.  There  is  great  danger  that  an  impacted  fracture  of 
the  hip  may  be  changed  by  rough  handling,    especially   in   the 


FRACTURK    OF    the;    HIP — MEASURIiMIiNT 


275 


movement  of  rotation,  to  an  unimpacted  fracture.  Palpation 
of  the  neck  of  the  femur  with  the  thumb  in  front  of,  and  the 
fingers  behind,  the  great  trochanter  will  detect  any  irregularity 
or  thickening  and  tenderness  about  the  neck  of  the  bone  (see 
Fig.  367).  By  palpation  of  the  great  trochanter  one  may  dis- 
cover there  the  seat  of  fracture.  vSwelling,  tenderness,  and 
crepitus  may  be  found.     Only  gentle  strong  traction  in  the  line 


Fig.  358. — Fracture  of  the  hip.  Inward 
rotation  of  the  leg  because  of  impaction  of 
the  anterior  portion  of  the  neck  of  the 
bone. 


Fig.  359. — Fracture  of  the  hip.  Out- 
ward rotation  of  the  leg  because  of  impac- 
tion of  the  posterior  portion  of  the  neck  of 
the  bone. 


of  the  long  axis  of  the  thigh  should  be  made  to  elicit  crepitus 
and  abnormal  motion. 

Measurement. — The  absence  of  any  preexisting  injury  or 
disease  of  the  hip  under  consideration  is  always  to  be  carefully 
noted.  Measurement  should  always  be  made  with  the  patient 
lying  on  the  back.  The  leg  should  be  brought  gently  along- 
side of  its  fellow,  and  steadied  by  an  assistant.  Measurement 
should  be  made  from  the  anterior  superior  spine  of  the  ilium  to 
the  internal  malleolus  upon  each  side  (see  Fig.  386).     If  there 


76 


FRACTURES    OF    THE    FEMUR 


is  shortening  upon  the  injured  side,  a  fracture  with  some  displace- 
ment is  hkelv  to  have  occurred.  A  normal  difTcrencc  in  the  length 
of  the  lower  limbs  is,  however,  not  unusual.  It  is,  therefore, 
necessary  to  determine  the  presence  of  asymmetry  if  it  exists, 
if  any  confidence  is  to  be  placed  in  the  measurements  of  the  legs. 
Measurements  should,  therefore,  be  made  of  the  tibia  upon  the 
two  sides,  and  these  compared.  If  no  asymmetry  appears 
to  be  present,  any  diflferences  in  measurement  may  be  taken 
to  be  absolute.      If  it  is  impossible  to  bring  the  legs  parallel,  they 


Fig.  360.— Old  fracture  of  femoral  neck  ; 
no  union.  Absorption  of  whole  neck  of 
bone.  The  contiguous  surfaces  of  the  frag- 
ments are  of  hard,  compact  bone.  There 
is  some  atrophy  of  the  whole  shaft  of  the 
femur  (Warren  Museum,  specimen  8075). 


Fig.  361. — Fracture  of  femoral  neck. 
Impaction  of  base  into  the  shaft,  with  down- 
ward and  inward  rotation  of  upper  frag- 
ment (Warren  Museum,  specimen  6303). 


must  be  placed  in  the  same  relative  positions  to  the  median  line 
of  the  body. 

Bryant's  method  of  measurement  is  simple  and  of  service.  The 
limbs  are  placed  symmetrically.  The  top  of  the  trochanter 
is  marked  upon  the  skin.  A  perpendicular  line  is  dropped  from 
the  anterior  superior  spine  to  the  table  upon  which  the  patient 
lies.  Measurement  is  made  from  the  top  of  the  trochanter  to 
this  perpendicular  line.  If  fracture  of  the  neck  of  the  femur 
has  occurred,  and  there  is  displacement  or  shortening  of  the 
limb,  the  distance  from  the  perpendicular  to  the  top  of  the  tro- 
chanter will  be  less  than  a  like  measurement  on  the  uninjured 
side.  The  position  of  the  top  of  the  great  trochanter  is  deter- 
mined with  reference  to  Xelaton's  line.      If  the  leg  is  rolled  out- 


FRACTURE    OF    THE    HIP — MICASMREMI' NT 


!77 


ward,  dislocation  of  the  hip  forward  would  be  suspected,  but  the 
absence  of  the  head  of  the  bone  anteriorly  and  the  absence  of 


Pig.  362.— Fracture  of  the  neck  of  the  femur  close  to  the  head  at  outer  part  of  the  neck 
(Warren  Museum  specimen). 


Fig.  363.— Fracture  of  the  neck  of  the  femur  at  base  (Warren  Museum  specimen). 


other    positive    signs    should    eliminate    dislocation.     If    the    leg 
is  rolled  inward,  a  dislocation  of  the  hip  upon  the  dorsum  ilii 


"78 


FRACTl'RES    OF    THE    FEMl^R 


would  be  considered.  The  absence  of  other  positive  signs  of 
dislocation  and  the  presence  of  the  head  of  the  bone  in  the  acet- 
abulum should  convince  one  of  the  nonexistence  of  dislocation. 
In  an  elderly  person  who  presents  no  well-marked  sign  of  frac- 
ture, but  who  is  unable  to  use  the  limb  after  ever  so  slight  an 
injury,  a  fracture  of  the  hip  should  be  so  strongly  suspected  that, 
until  the  Rontgen  ray  proves  it  absent,  he  should  be  treated 
as  if  a  fracture  were  present. 

Prognosis  am!  Result. — In  the  verv  aged  and  feeble  the  shock 
of  a  fracture  of  the  neck  of  the  femur  is  severe.  The  danger 
to  life  in  these  cases  is  great.  An  elderly  patient  mav  die  of 
shock  within  two  or  three  days,  or  within  a  week  of  hypostatic 


Fig.  364. — Fracture  of  femoral  neck,  unimpacted  ;  fibrous  union,  with  absorption  of  the  neck 
(Warren  Museum,  specimen  3651). 


pneumonia,  or  he  may  live  several  weeks  and  die  of  exhaustion 
because  of  pain  and  the  enforced  confinement.  If  the  fracture 
can  be  treated  with  proper  immobilization,  union  will  occur 
in  most  cases.  The  impacted  cases  will  unite ;  the  unimpacted 
cases  may  unite.  Slight  shortening  with  a  little  deformity, 
some  limitation  in  the  movements  of  the  hips,  a  limp,  but  a 
fairly  useful  limb,  are  to  be  hoped  for.  Chronic  rheumatism 
will  often  prevent  a  fractured  hip  from  ever  becoming  useful. 
Nonunion  of  the  hip-fracture  does  not  preclude  a  useful  limb 
(see  Fig.  368).  Ununited  fractures  of  the  hip  are  greatly  bene- 
fited by  proper  ambulatory  apparatus.  They  may  be  made 
to  unite  by  mechanical  means  even  several  weeks  and  months 


FRACTURE    OF    THE    HIP — PROGNOSIS  279 

after  the  injury.     This  is  particularly  true  of  fractures  occurring 
in  young  adults. 


Fig.  365— Fracture  of  the  neck  of  the  femur  (Warren  Museum  specimen). 


Fig.  366. — Note  line  of  fracture  extending  into  shaft. 

Results  after  Fracture  of  the  Hip.—Oi  especial  value  in  this 
connection  are  the  conditions  existing  in  sixteen  cases  of  frac- 


2So  FRACTIKHS    OF    THE    FEMUR 

ture  of  the  hip.  many  years  after  the  aecident.  These  sixteen 
cases  were  treated  at  the  Massachusetts  General  Hospital  by 
traction  and  immobilization,  for  periods  varyinc^  from  a  few 
weeks  to  a  few"  months.  The  patients  then  went  cd)()ut  with 
crutches.  Xo  other  treatment  was  used.  Nearly  all  the  cases 
were  unimpacted  either  primarily  or  secondarily.  At  the  time 
of  the  accident  seven  cases  were  between  forty-two  and  forty- 
seven  years  old,  the  remainder — with  two  exceptions,  whose 
ages  are  not  stated — were  over  fiftv;  three  were  over  sixty  years 
old.  These  cases  reported  for  examination  from  two  and  one- 
half  to  twentv-four  and  one-half  years  after  the  accident.  Thir- 
teen of  the  sixteen  cases  have  impairment  of  the  functional  use- 
fulness of  the  leg;  a  weakness  of  the  limb,  necessitating  a  crutch 
in  many  instances;  all  movements  at  the  hip  somewhat  restricted; 


Fig.  367. — Method  of  palpating  the  trochanter  of  the  riglit  femur. 

atrophy  of  the  muscles  of  the  thigh,  buttock,  and  calf  of  the 
leg;  a  decided  limp,  requiring  a  cane;  pain  in  the  hip  extending 
down  the  thigh  even  to  the  sole  of  the  foot ;  pain  at  night  in  the 
hip;  pain  in  going  up-stairs  and  in  stooping  over.  In  only  two 
cases  out  of  the  sixteen  could  it  be  said  that  the  leg  was  func- 
tionally useful. 

Treatment. — General  Considerations. — Fractures  of  the  hip  or 
of  the  neck  of  the  femur  demand  the  greatest  tact  in  their  manage- 
ment. The  aged  respond  readily  to  care.  The  patient  should 
be  made  to  feel  as  comfortable  as  possible  while  confined  to  his 
bed.  Particular  attention  should  be  paid  to  diet  and  to  all  little 
comforts.  The  discomforts  attendant  upon  immobilization  are 
often  verv  great.  Let  the  days  spent  in  bed  be  made  especially 
attractive.      Be    sure    that    agreeable    friends    visit    the    patient, 


FRACTURE    OF    THIJ    HIP— TREATMICNT 


281 


seeing  to  it  that  they  do  not  stay  so  long  a  time  as  to  weary  him. 
Let  them  interest  him  in  the  news  of  the  day,  so  that  he  may 
feel  that  he  is  keeping  up  with  events.  Employ  a  skilled  nurse 
to  minister  to  his  wants;  a  bright  and  cheerful  woman  nurse 
is  ordinarily  better  than  a  man  nurse.  The  pulse  is  to  be  care- 
fully watched  as  well  as  the  respiration.  A  moderate  amount  of 
alcohol  once  or  twice  a  day  with  meals  is  to  be  used.  The  courage 
of  the  aged  needs  bracing.  Bed-sores  develop  with  surprising 
rapidity.     Skilled    watchfulness   and    immediate   treatment    will 


Fig.   368.— Case  :  Man   forty-five   years   old.      Fracture  of   the  neck  of  the  femur.      Union 
ligamentous,  with  displacement.     Useful  limb  (X-ray  tracing). 


often  check  the  progress  of  a  red  pressure  spot.  The  part  ex- 
posed to  pressure  should  be  kept  very  clean  with  soap  and  warm 
water;  it  should  be  bathed  with  alcohol,  thoroughly  dried,  and 
well  dusted  with  powder  (starch  and  oxid  of  zinc,  equal  parts) ; 
and  the  pressure  should  be  relieved  by  proper  pads  or  cushions. 
If  the  heel  is  the  part  involved,  a  rubber  cushion  or  a  ring  made  of 
sheet  wadding  wound  with  a  bandage  may  be  used.  A  certain 
amount  of  moving  about  in  bed  should  be  granted  to  old  people. 
Asthenic  hypostatic  pneumonia  from  long-continued  resting 
in  one  position  is  not  uncommon.     Therefore,  moving  about  a 


282 


FRACTURES    OF    THE    FEMUR 


lilllc  in  bed,  to  the  extent  of  sitting  upon  a  bed-rest  at  varying 
angles,  is  beneficial.  Deep  rhythmical  breathing  while  lying 
flat  on  the  back  is  a  splendid  stimulator  of  the  circulation.  In 
the  case  of  a  fracture  of  the  neck  of  the  thigh-bone  occurring 
in  an  elderly  individual  treat  the  patient  and  let  the  fracture 
be  of  almost  secondary  importance. 

Treatment  of  the  Fractured  Hip. — The  patient  should  be  placed 


y 


Fig.  369. — Case  :  Fracture  of  the  neck  of  the  femur  (X-ray  tracing). 


upon  a  comfortable,  firm,  hair  mattress.  Underneath  the  mat- 
tress, crossing  the  bedstead  from  side  to  side,  should  be  placed 
several  wooden  slats  about  eight  inches  apart.  These  bed- 
slats  prevent  sagging  of  the  mattress  and  much  consequent 
discomfort.  Great  caution  must  be  exercised  that  no  sudden  or 
forcible  movements  of  the  hip  are  made  which  might  break  up 
the  impaction  of  the  bone  or  cause  unnecessary  pain.  The  leg 
should  be  placed  in  as  natural  a  position  in  extension  as  possible. 


FRACTURE    OF    THE    HIP — TREATMENT  283 

The  knee  should  be  placed  upon  a  pillow.  Extension  strips  of 
adhesive  plaster  should  be  applied  to  the  leg  and  thigh  as  high  as 
the  perineum,  and  should  be  held  to  the  skin  by  a  gauze  roller 
bandage.  A  weight  of  about  five  pounds  should  be  applied  to 
the  extension  while  the  leg  is  gently  rotated  and  carefullv  placed 
approximately  in  the  normal  position.  The  foot  of  the  bed 
should  be  elevated  to  the  height  of  six  inches  in  order  to  secure 
counterextension.  Long  and  heavy  sand-bags  should  be  placed 
on  each  side  of  the  leg  and  thigh  to  assist  the  light  extension 
in  affording  support  and  to  give  a  sense  of  security.  The  heel, 
as  mentioned  before,  should  be  properly  protected  from  undue 
pressure.  The  foot  should  be  kept  at  a  right  angle  with  the  leg. 
To  afford  ?till  greater  immobilization,  a  long  T-splint  extending 
from  below  the  foot  to  the  axilla  of  the  injured  side  may  be  applied 
by  straps  about  the  leg  and  a  swathe  about  the  body  (see  Fig. 

398). 

After-care  of  the  Simple  Traction  Method. — The  general  care 
of  the  patient  should  be  as  outlined  previously.  He  should  be 
kept  quiet  in  bed  for  about  two  weeks.  During  the  second 
week  he  may  be  bolstered  up  on  pillows  to  the  half-sitting  posi- 
tion. Ordinarily,  the  extension  may  be  removed  during  the 
third  week.  The  patient  may  then  be  lifted  to  another  bed 
or  divan  and  be  rolled  into 'an  adjoining  room.  In  this  change 
the  thigh  should  be  supported  by  sand-bags.  The  patient  may 
be  up  in  a  wheel-chair  after  the  first  six  weeks  or  two  months 
with  the  knee  straight  on  a  board  or,  if  comfortable,  flexed.  He 
may  use  crutches  and  a  high  shoe  upon  the  well  foot,  not  bearing 
any  weight  upon  the  injured  hip,  after  about  two  months  or 
ten  weeks.  He  should  not  bear  weight  upon  the  hip  even  with 
the  assistance  of  crutches  for  about  three  or  four  months.  At 
the  end  of  a  year  he  may  be  walking  with  one  cane.  The  fore- 
going is  the  course  of  a  case  treated  according  to  the  old-time 
simple  extension  or  partial  immobilization  method.  It  is  a 
matter  of  common  observation  that  some  impacted  hips  recover 
with  fairly  useful  limbs  with  this  treatment.  Impacted  hips  are 
known  to  have  recovered  with  useful  limbs  without  any  medical 
or  surgical  advice  or  treatment  the  impacted  fracture  having 
been  thought  at  the  time  of  the  injury  to  be  a  severe  contusion 


284  FRACTl'RES   OF    THE    FEMUR 

which   would  be  all  right   in   time.      These  cases  have  occurred 
both  among  adults  and  children. 

Greater  immobilization  of  the  impacted  and  unimpacted  hip 
is  demanded  in  most  cases  than  can  be  obtained  by  the  simple 
traction  and  countertraction  previously  described.  The  simple 
method  is  far  from  ideal:  malunion  and  nonunion  with  resulting 
disabilitv  too  often  follow  its  use,  the  period  of  disability  is  long, 
and  the  ultimate  results  are  often  most  unsatisfactory.  Very 
refractory  individuals  will  have  to  be  left  pretty  much  to  them- 
selves.    No  great  restraint  can  to  advantage  be  forced  upon  them. 


Fig.  370. — Thomas'    single  hip-splint   in 
position  (Ridlon). 


Fig.  371. — Thomas'  double   hip-splint  in 
position  (Ridlon). 


The  Fixation  Method  of  Treatment. — In  order  to  put  the 
unimpacted  bones  of  the  hip-joint  under  the  very  best  con- 
ditions for  union  to  take  place  not  only  must  the  fragments  be 
approximated  by  traction,  correction  of  eversion  or  inversion, 
and  lateral  pressure  over  the  trochanter  major,  but  these  frag- 
ments must  be  firmly  fixed.  In  order  to  immobilize  these  frag- 
ments absolutely  the  body  or  pelvis  and  the  thigh  must  be  fixed. 
The  simple  method  already  described,  in  spite  of  the  fact  that 
it  has  been  used  for  many  years  in  these  cases,  does  not  absolutely 


FRACTURE    OF    THE    HIP— TREATMENT  285 

immobilize.  The  most  comfortable  and  efficient  method  of 
immobilization  is  by  the  use  of  the  Thomas  hip-splint.  The 
description  which  follows  of  the  Thomas  hip-splint  and  its  use 
is  that  given  by  Ridlon. 

The  Thomas  hip-splint  secures  posterior  support  to  the  frac- 
ture, gives  fixation  without  compression  of  the  fractured  region 
except  posteriorly,  allows  the  patient  to  be  lifted  with  ease,  does 
not  interfere  with  the  groin,  favors  cleanliness,  admits  of  trac- 
tion, can  be  applied  without  moving  the  patient  and  without 
assistance,  and  presents  no  difficulties  after  the  initial  application 
(see  Figs.  370,  371). 

The  splint  is  made  of  soft  iron,  and  consists  of  a  main  stem,  a 
chest-band,  a  thigh-band,  and  a  calf -band.  The  stem  is  an  inch 
and  a  quarter  wide  and  one-fourth  of  an  inch  thick,  and  in  length 
reaches  from  the  axilla  to  the  calf  of  the  leg — the  length  of  the 
lower  portion  from  the  hip-joint  to  the  calf  of  the  leg  being  equal 
to  that  from  the  axilla  to  the  hip- joint.  In  the  part  opposite 
the  buttock  two  gentle  bends  are  made,  the  lower  somewhat 
backward  and  the  upper  upward,  so  that  the  body  and  leg  por- 
tions of  the  splint  follow  parallel  lines  from  one-half  to  one  inch 
apart,  the  body  portion  being  posterior  to  the  leg  portion.  The 
stouter  the  patient,  the  more  nearly  do  these  parallel  lines  coin- 
cide, and  in  some  cases  the  main  stem  may  be  felt  entirely  straight. 
To  the  lower  end  is  fastened,  by  one  rivet,  the  calf-band,  one- 
sixteenth  by  five-eighths  of  an  inch,  and  in  length  an  inch  or 
two  less  than  the  circumference  of  the  leg  at  this  point.  The 
thigh-band  is  one-sixteenth  by  three-fourths  of  an  inch,  and  in 
length  an  inch  or  two  less  than  the  circumference  of  the  thigh 
at  its  largest  part;  it  is  riveted  to  the  main  stem  just  below  the 
lower  bend,  so  that  when  applied  to  the  patient,  it  comes  well 
up  to  the  perineum.  The  chest-band  is  three-thirty-seconds 
by  one  and  one-fourth  inches,  and  in  length  nearly  equal  to  the 
circumference  of  the  chest,  being  relatively  longer  than  the  other 
bands.  It  is  fastened  by  one  rivet  after  the  upper  end  of  the  stem 
has  been  forged  flat  and  bent  back  over  it.  This  arrangement 
makes  a  fast  joint,  and  brings  the  stem  between  the  chest-band 
and  the  skin.  In  each  end  of  the  chest-band  a  round  hole  is 
forged  of  at  least  one-half  of  an  inch  in  diameter. 


286  FRACTURES    OF   THE    FEMUR 

Siininiarv  of  material  and  measurements  required  in  making 
the  Thomas  splint : 

Stem,  i^  inches  wide,  ]  inch  thick,  extending  from  the  axilla 
to  the  calf  of  the  leg. 

Calf-band,  ;>;  inch  wide,  yV  inch  thick:  the  length  is  two  inches 
less  than  the  circumference  of  the  calf  of  the  leg. 

Thigh-band,  j  inch  wide,  yV  inch  thick ;  the  length  is  two  inches 
less  than  the  largest  circumference  of  the  thigh. 

Chest-band,  ij  inches  wide,  -/tt  inch  thick;  the  length  to  nearly 
equal  the  circumference  of  the  chest. 

A  hole  is  forged  at  each  end  of  the  chest-band,  ^  inch  in  diam- 
eter. Any  good  blacksmith  can  make  this  splint  in  a  very  short 
time. 

The  splint  is  now  bent  to  fit  approximately  the  patient,  padded 
on  the  side  that  is  to  come  next  the  skin  with  a  quarter-inch 
thickness  of  felt,  care  being  taken  to  leave  no  inequalities  of 
surface,  and  then  covered  with  basil  leather  put  on  wet  and 
tightly  drawn,  so  that  when  dry  it  will  have  shrunk  sufficiently 
to  prevent  the  cover  from  slipping  on  the  iron.  The  splint  is 
applied  by  opening  out  the  wings  of  the  bands  looking  to  the 
uninjured  side  of  the  patient,  and  then  slipping  them,  followed 
by  the  stem,  underneath  the  patient  from  the  injured  side;  the 
wings  that  were  straightened  are  bent  again  by  hand  and  readily 
return  to  their  former  curves.  A  closer  and  more  accurate 
adjustment  of  the  wings  may  be  made  by  the  use  of  wrenches; 
these  will  be  found  especially  serviceable  in  fitting  the  chest- 
band  and  in  drawing  in  the  other  bands  when  the  patient  is  very 
intolerant  of  any  threatened  movement  or  jarring. 

"The  splint  having  been  fitted,  if  retentive  traction  is  not 
required,  the  limb  is  bandaged  to  the  stem  from  the  calf  to  the 
upper  part  of  the  thigh,  rolling  the  bandage  in  the  direction  the 
opposite  to  the  rotary  deformity  that  may  be  present;  then 
shoulder-straps  are  applied  by  taking  a  couple  of  yards  of  broad 
bandage  or  a  strip  of  muslin,  looping  it  round  the  stem  where 
it  joins  the  chest-band,  then  over  the  band  and  over  the  shoulders, 
and  down  to  the  ends  of  the  chest-band.  Here  it  is  passed  through 
the  holes  and  tied ;  then  it  is  passed  across  the  intervening  space 
to   the   opposite   hole   and   again   tied.     If  retentive   traction   is 


FRACTURE   OF    THE    HIP — TREATMENT 


287 


desired,  the  shoulder-straps  are  omitted.  To  each  side  of  the 
limb  from  the  upper  part  of  the  thigh  after  the  limb  has  been 
pulled  down  to  the  splint  a  broad  strip  of  adhesive  plaster  is 
applied.  The  lower  ends  of  the  plaster  are  turned  outward  and 
upward  around  the  wings  of  the  calf-band,  where  they  are  fastened 
by  a  strip  of  plaster  passed  entirely  around  the  limb;  the  whole 
is  then  covered  with  a  bandage.     By  this  arrangement  the  limb 


Fig.  372. — Tracing  of  photograph  of  patient  (see  skiagram,  Fig.  373)  four  years  after 
fracture  of  the  left  femoral  neck,  showing  the  shortening  and  turning  out  of  the  leg  (after 
Whitman). 


is  pulled  upon  only  to  the  extent  of  correcting  the  actual  shorten- 
ing, and  is  held  at  one  and  the  same  length  sleeping  or  waking, 
whether  the  muscles  relapse  or  are  spasmodically  contracted. 

' '  The  device  aims  to  prevent  motion  in  the  axis  of  the  limb ; 
to  prevent  lateral  motion  by  bending  the  limb  in  any  direction; 
to  do  this  without  constricting  the  region  of  the  fracture;  and 
to   enable   the   patient  to  have   the   bed-pan   adjusted   without 


288  FRACTURES    OF    THE    FEMUR 

pain  and  without  disturbing;  the  rehition  of  the  parts.  When 
the  sphnt  has  been  appHed  and  the  patient  is  in  bed,  the  nurse 
should  be  instructed  in  certain  manocuvers.  The  bed-pan  is 
adjusted  by  passing  the  arm  under  both  hmbs  or  below  the 
knees  and  then  lifting  directlv  upward,  making  an  incline  of  the 
whole  patient  below  the  chest-band.  By  this  mana'uver  it  is 
also  more  easv  to  smooth  out  wrinkles  in  the  bedding  and  change 
the  sheet  than  in  the  usual  way.  The  stem  should  be  made  to 
press  upon  different  parts  of  the  skin  by  pulling  the  skin  night 
and  morning  first  to  one  side  and  then  to  the  other.  The  patient 
should  be  inspected  dailv  for  pressure  sores  by  turning  him  on 
the  sound  side.      In  order  to  turn  a  patient  upon  the  sound  side 


Fig.  373. — Skiagram  tracing  of  patient  two  and  a  half  years  of  age,  after  the  accident, 
illustrating  the  deformity  of  the  neck  and  of  the  upper  extremity  of  the  shaft,  also  the  eleva- 
tion of  the  pelvis  on  the  affected  side  (after  Whitman). 


support  the  fractured  limb  at  the  knee  with  one  hand  and  grasp 
the  chest-band  with  the  other;  the  patient  then  is  readily  turned 
as  a  whole.  The  points  most  likely  to  suffer  from  pressure  are 
those  at  the  junction  of  the  thigh-band  and  stem,  the  lower 
bend  of  the  stem,  and  the  junction  of  the  stem  and  chest-band. 
Points  pressed  upon  should  be  tightly  dressed  with  flexible  col- 
lodion and  protected  from  further  pressure  by  padding  above 
and  below.  If  the  pressure  of  the  whole  body  portion  of  the 
stem  is  complained  of,  a  small,  thin  mattress  of  hair  or  a  sheet 
folded  to  several  thicknesses  may  be  placed  between  the  splint 
and  the  patient's  back.  Threatened  hypostatic  congestion  is 
obviated  by  raising  the  head  of  the  bed  from  one  to  three  feet, 


FRACTURE    OF    THE    HIP — TREATMENT  289 

the  patient  meanwhile  being  prevented  from  sHpping  down  by 
tying  the  spHnt  to  the  head  of  the  bed.  In  all  cases  obviously 
unimpacted  and  in  all  cases  when  the  shortening  is  more  than 
three-fourths  of  an  inch,  traction  should  be  applied. 

"  In  all  cases  the  splint  should  be  kept  on  for  from  six  to  eight 


Fig.  374. — Tracing  of  photograph  of  patient  eiglit  years  old,  some  years  after  a  fracture 
of  the  neck  of  the  right  femur,  showing  great  projection  and  elevation  of  the  trochanter, 
made  more  apparent  by  flexing  the  thigh  and  leg  (Whitman). 

weeks  after  all  pain  has  ceased;  then  the  patient  should  remain 
in  bed  four  weeks  longer  without  any  treatment  whatever,  unless 
there  is  some  positive  indication  to  the  contrary,  in  which  case 
the  splint  is  cut  off  at  the  knee  and  the  calf-band  riveted  at  this 
point  and  the  patient  permitted  to  go  about  with  crutches." 
In  addition  to  the  use  of  the  Thomas  splint,  it  may  be  wise  to 
19 


Head  nf  finiiir 


Marks  upper  limit  o{  lieail  of  bone. 


Fig.  375. — Case  :  Girl  13  years  of  age.     Old  fracture  of  shaft  of  femur  witfi  vicious  union. 
Fresh  fracture  of  neck  of  femur. 


290 


fracture;  of  nkck  of  frmur  in  chiijjrkn  29; 

make  lateral  pressure,  as  suggested  by  vSenn,  over  the  trochanter 
of  the  broken  hip  with  the  expectation  of  more  firmly  fixing  the 
broken  bone.  Lateral  pressure  may  be  secured  by  a  surcingle 
or  by  a  bandage  applied  over  a  graduated  compress.  The  spot 
to  which  pressure  is  applied  should  be  carefully  watched  and 
protected,  lest  a  pressure  sore  appear. 

The  Operative  Treatment. — Suturing  or  pegging  the  fragment 
is  very  properly  to  be  reserved  for  fractures  occurring  in  young 
adults  in  whom  the  absolute  fixation  by  the  Thomas  splint  for 
a  reasonable  period  has  not  effected  union. 

Fracture  of  the  Neck  of  the  Femur  in  Childhood. — Whitman 
has  called  especial  attention  to  this  fracture.  The  anatomical 
proof  of  the  existence  of  fracture  of  the  neck  of  the  femur  in 
childhood  has  been  furnished  by  the  specimens  of  Bolton,  Meyers, 
and  Starr.  The  fracture  occurs  after  traumatism  to  the  hip 
probably  more  frequently  than  separation  of  the  upper  femoral 
epiphysis.  It  is  not  so  uncommon  an  accident  as  has  been 
supposed.  The  fracture  is  probably  impacted  or  greenstick. 
The  clinical  picture  of  fracture  of  the  neck  of  the  femur  in  child- 
hood differs  greatly  from  that  furnished  by  a  similar  injury  in 
old  age.  In  the  first  instance  a  healthy  child  falls  from  a  height, 
and  presents  a  shortening  of  the  thigh  of  from  one-half  to  three- 
quarters  of  an  inch.  There  are  slight  outward  rotation  of  the 
leg  and  limitation  of  motion  and  slight  discomfort  in  the  hip. 
The  child  may  walk  about  after  a  few  days  with  but  a  little 
lameness  to  suggest  that  any  injury  has  been  received.  The 
child  recovers  with  a  limp.  Months  or  years  later  signs  of  coxa 
vara  appear.  In  childhood  a  rather  severe  injury  is  followed 
by  immediate  symptoms,  and  later  by  great  disability.  On  the 
other  hand,  in  old  age  a  trivial  injury  is  followed  by  immediate 
and  complete  disability.  It  is  often  overlooked  in  the  child  and 
is  treated  for  a  contusion  or  sprain  of  the  hip.  The  immediate 
result,  however,  is  extremely  good  even  without  more  than 
bed  treatment,  but  the  ultimate  result  after  several  months  or 
years  may  be  disastrous  because  of  the  disability  due  to  a  gradu- 
ally increasing  bending  of  the  femoral  neck.  The  late  result 
of  fracture  of  the  femoral  neck  in  childhood  resembles  hip-disease 
in  the  limp,   slight  pain,   shortening,   deformity,   and  limitation 


2  =  2'^ 

.2  ° 

£  s ':  .2  ^ 

in  -u  ^  ;2  5 

•<    u  m    S  IH 

<j^  '5  "5  ^  "C! 

•^  3  -   =  ii 

isi  i;  o  £  B 


—      a; 

h 

^ 

5 

a> 

u 
11 

2. 

s 

5   a- 

3 

"o 

« 

"o 

iS 

a; 

5 

E 

c 

_0 

^ 

- 

rt 

= 

3 

o    rt 

"o 

5 

11 

■a 

lU 

<  t 

^ 

11 

0 

« 

- 

1     -■ 

o 

— 

jj^ 

■— 

3 

i  ^ 

- 

a 

0 

2 

?.  « 

u 

S- 

M 

ro  c; 

(u 

B 

rt 

E  £ 

o 

5 

T3 

5 

^ 

X 

0 

o 

^ 

— 

■7. 

s 

- 

c 

— 

2  i 

5 

6 

(3! 
0 

5 

5 

o 

>< 

C 
o 

C3 

(U 
0) 

s 

j=  ^ 

Oj 

ri 

a 

^ 

OJ 

.- 

o 

'o 

<    >• 

6 

1 

1= 

V- 

j: 

-;;- 

1    a. 

M 

a 

■^ 

5 

t^  a. 

w 

^ 

r3 

3 

3 

r^    o 

a  j= 

,o 

j: 

13 

"Z 

o 

•— 

bi  5 

o 

§; 

5 

jr 

% 

j; 

E  S 

I3l 

'9 

(U 

■z. 

(U 

0 

■*H 

c 

^ 

u^ 

'rt 

*^ 

o 

o 

0 

o 

^     in 

p 

o 

i 

13 

V 

5. 
11 

u 

O    «;' 

oi 

rt 

CC 

^ 

>->^ 

•c 

u 

s; 

rt 

p 

B 

2  o 

1-    bt 

0; 

(LI     OJ 

f 

3 

rt 

,c 

^ 

<u 

tu 

I-    "^ 

a.  rt 

•^ 

^5 

a! 

^     'U 

'•^' 

rt 

(L* 

^  -^ 

"a. 

(P 

2: 

bfl 

1       y 

'5. 

i^ 

aJ 

-6    a 

u< 

pr    X 

^ 

■c 

;;: 

CS 

M 

rt 

■!2 

E  s 

? 

E 

« 

« 

o 

rt 

5 

j= 

-p 

i; 

<u 

u^:    tfl    o 


292 


fracture;  of  the;  shaft  of  the;  fe;mur  293 

of  motion  present.  Care  must  be  taken  not  to  confound  the 
two  conditions.  These  later  stages  of  fracture  are  to  be  treated 
by  rest  to  the  joint.  All  body-weight  and  the  jar  of  walking 
are  to  be  removed  by  a  properly  fitting  hip-splint  with  traction. 
Refracture  and  operative  measures  are  to  be  seriously  enter- 
tained, as  in  other  forms  of  coxa  vara,  particularly  if  the  disability 
is  great  or  is  increasing  (see  Figs.  374-379  inclusive). 

The  treatment  of  a  fresh  greenstick  or  impacted  fracture  of  the 
hip  in  children  should  be  by  rest  on  the  back  in  bed  and  moderate 
traction  and  immobilization  of  the  hip  and  thigh  and  body. 
After  a  month  the  child  may  be  allowed  up,  wearing  a  traction 
hip-splint  for  several   months  until  union  is   so   firm  that   the 


Fig.  380. — Fracture  of  the  thigh  at  the  middle.     Characteristic  deformity. 

danger  from  coxa  vara  is  practically  eliminated.  A  light  plaster- 
of- Paris  spica  bandage  from  calf  to  axilla  will  maintain  im- 
mobility after  the  splint  is  omitted. 

FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR 
Fracture  of  the  shaft  of  the  femur  is  usually  oblique.  It  is 
situated  either  just  below  the  lesser  trochanter  (subtrochanteric 
fracture),  at  the  center  of  the  shaft,  or  above  the  condyles  (supra- 
condyloid  fracture).  Even  in  closed  fractures  there  is  some- 
times great  damage  to  the  soft  parts:  the  vessels  of  the  thigh 
are  at  times  injured. 


294 


FRACTURES   OF    THE    FEMUR 


Symptoms. — There  is  often  great  swelling  at  the  seat  of  frac- 
ture. The  limb  lies  helpless.  Pain,  abnormal  mobility,  de- 
formity, marked  rolling  of  the  leg  below  the  seat  of  the  frac- 
ture, and  crepitus,  one  or  all,  may  be  evident  (see  Figs.  380, 
381).     The  hmb  is  shortened. 

Measurement  (see  Figs.  384-387  inclusive)  to  determine  the 
amount  of  the  shortenings  is  to  be  made  from  the  anterior  superior 
spinous  process  of  the  ilium  to  the  internal  malleolus  of  the 
same  side.  Great  care  nmst  be  exercised  in  taking  this  measure- 
ment so  that  the  patient  lies  flat  upon  the  back  upon  a  hard  and 
even  surface,  with  the  arms  at  the  sides  of  the  body  and  with 


Fig.  381.— Fracture  of  the  right  femur  at   the   middle.     Characteristic   deformity.     Inward 
rotation  of  leg  below  fracture. 


no  pillow  under  the  head  or  shoulders.  The  long  axis  of  the 
body  should  be  in  the  same  line  with  the  long  axis  between  the 
legs  as  they  lie  with  the  malleoH  approximated — i.  e.,  the  chin, 
episternal  notch,  umbilicus,  the  symphysis  pubis,  the  midpoint 
between  the  knees,  and  the  midpoint  between  the  internal  mal- 
leoH should  all  be  in  one  straight  hne  (see  Fig.  387).  The  line 
joining  the  anterior  superior  spinous  processes  of  the  ilia  should 
be  at  right  angles  to  this  long  axis  of  the  body  and  thighs.  Any 
variations  from  this  normal  position  are  attended  by  errors  in 
measurement,  which  are  important.  If  for  any  reason  the  in- 
jured thigh  can  not  be  brought  easily  alongside  its  fellow,  the 


«*■ 


liii  m 


FTig.  382.— Fracture  of  the  upper  third  of  the  shaft  of  the  right  femur  (X-ray  tracing). 


Fio-  383-— Long  oblique  fracture  of  the  shaft  of  the  femur  (Massachusetts  General  Hospital, 

1250.     X-ray  tracing). 

295 


?96 


FRACTURUS    OK    TIIH    I'liMlR 


two  limbs  should   be  placed   as  nearly  symmetrical   with   refer- 
ence to  the  median  line  as  possible. 

The  method  of  measuring  the  lengths  of  the  lower  extremities 
used  bv  Dr.  Keen  differs  from  the  above  in  that  he  uses  the 
malleolus  as  the  hxed  point,  and  measures  to  a  line  drawn  at 
the  anterior  superior  spinous  processes  of  the  ilium.     The  finger 


Fig.  384.— Fracture  of  the  thigh.     Correct  method  of  measurement  from  the  anterior  superior 
spinous  process  of  the  ilium.     Position  of  thumb  and  finger  holding  tape. 


Fig.  385. — Measurement  of  lower  extremity.     Position  of  thumbs  shown.     Xote  position  of 

limb. 


and  tape  are  not  allowed  to  touch  the  skin-mark,  and  so  do  not 
displace  it. 

Treatment  of  Fracture  of  the  Shaft  of  the  Femur. — The 
Transportation  of  a  Patient:  The  emergency  method  of  putting 
up  a  fracture  of  the  thigh  or  hip  is  of  very  great  practical  im- 
portance (see  Fig.  388).     Limbs  are     fractured  frequently  some 


fracture;    of    shaft    of    FIJMUR — TRIiATMUNT 


297 


distance  from  the  proper  place  for  the  apphcation  of  the  pur- 
manent  dressing.  It  is  necessary  to  transport  such  cases  with 
the  greatest  degree  of  safety  and  comfort.  In  order  to  accom- 
plish this  the  knee-  and  hip-joints  should  be  extended,  the  leg 
being  held  straightened  in  the  long  axis  of  the  body.  The  limb 
should  be  placed  upon  a  heavily  padded  board,  the  width  of  the 
thigh,  extending  from  the  middle  of  the  calf  to  above  the  sacrum. 
The  side  splints  of  wood  should  be  used — one  on  the  outer  side 


Fig.  386. — Measurement  of  lower  extremity.    Patient  lying  on  the  back  looked  at  from  above. 
Position  of  tape,  hands,  and  limbs  to  be  noted. 


extending  from  the  side  of  the  foot  to  the  axilla,  the  other  upon 
the  inner  side  extending  from  the  side  of  the  foot  to  a  few  inches 
below  the  perineum.  Upon  the  front  of  the  thigh  is  placed  a 
coaptation  splint  extending  from  the  groin  to  the  patella.  All 
of  these  splints  are  carefully  padded,  preferably  with  folded 
sheets  or  pillow-cases  or  towels;  of  course,  in  emergency  work 
small  pillows  or  coats  or  shawls  may  be  utilized.  It  is  important 
that  the  padding  be  evenly  and  intelligently  arranged.     It  will 


>98 


FRACTURES   OF    THE    FEMUR 


be  necessary  to  place  a  wide  pad  between  the  npper  end  of  the 
long  outside  splint,  to  prevent  it  from  pressing  upon  the  ribs 
and  side  of  the  chest  and  causing  great  discomfort.  These 
splints  are  held  in  position  about  the  leg,  while  gentle  traction 


Fig.  387.— Measurement  of  the  length  of  the  lower  extremity.  Patient  represented  lying 
on  back,  looked  at  from  above.  The  line  joining  the  anterior  superior  spinous  processes  of 
ilia  (C,D)  should  be  at  right  angles  to  the  long  axis  of  the  body  (A,  B).  In  this  position  only 
can  comparable  measurements  be  made.     (Drawn  by  C.  Rimmer.) 


is  being  made  upon  the  limb,  by  straps  or  pieces  of  bandage 
placed  above  the  ankle,  below  the  knee,  above  the  knee,  at  the 
middle  of  the  thigh,  and  at  the  level  of  the  perineum.  The 
upper  end  of  the  long  outside  splint  is  held  to  the  side  by  a  swathe 


Fracture;  of  shaft  of  fe;mur — trkatment 


299 


about  the  body  and  splint.  The  patient  should  then  be  care- 
fully placed  upon  a  stretcher  (a  Bradford  frame  is  an  ideal  form 
of  stretcher)  improvised  for  the  occasion.  With  this  apparatus 
snugly  applied,  the  patient  may  be  securely  and  comfortably 
transported. 

The  objects  of  treatment  are  to  reduce  the  fracture,  to  main- 
tain the  reduction  immobilized  until  union  is  firm,  and  to  restore 
the  leg  to  its  normal  usefulness.  In  the  treatment  of  two  of  the 
three  varieties  of  fracture  of  the  femur  permanent  traction  upon 


Fig.  388. — Fracture  of  hip  or  thigh.     Emergency  apparatus. 


Fig.  389. — Fracture  of  the  "thigh.     Method  of  holding  leg  in  order  to  detect  fracture  of  the 
thigh.     Pelvis  is  steadied  by  an  assistant. 


the   lower  fragment   and   permanent   countertraction   upon   the 
upper  fragment  are  necessary. 

The  patient  with  a  fractured  thigh  should  always  be  anes- 
thetized before  putting  the  thigh  up  permanently.  Never 
anesthetize  the  patient  until  all  the  different  parts  of  the  apparatus 
are  ready  and  on  a  table  near  the  bed  of  the  patient.  Always 
put  the  thigh  up  in  temporary  dressings  until  all  is  prepared  for 
the  permanent  splints.  About  one  hour  will  be  consumed  in 
applying  the  extension  apparatus  after  the  patient  is  anesthe- 
tized.    There  will  be  no  harm  in  letting  the  patient  rest  com- 


300 


FRACTURES    OF    THE    FEMUR 


fortabh-  in  the  temporary  splints  over  one  night  until  all  neces- 
sary arrangements  have  been  made  for  the  permanent  dressing. 

Method  of  Examination:  The  patient  is  completely  anesthe- 
tized in  order  to  secure  muscular  relaxation.  Accurate  ex- 
amination is  now  made  of  the  "fracture.  If  the  ends  of  the  frag- 
ments lie  close  to  the  skin,  great  care  must  be  exercised,  by 
steadying  the  thigh,  to  prevent  them  being  pushed  through  the 
skin  and  thus  rendering  the  fracture  an  open  one.  An  assistant 
should  steady  the  pelvis  and  upper  thigh  (see  Fig.  389).  The 
surgeon  should  grasp  the  thigh   above  the  condyles  with  both 


Fig.  390. — Pulley  arranged  on  hrooin-haiidlc  lo  be  fastened  at  foot  of  bed  for  carrying  exten- 
sion cord. 


hands,  and  should  make  traction  in  the  axis  of  the  limb.  He 
then  determines  the  pull  necessary  to  be  exerted  to  hold  the 
fragments  reduced.  While  this  pull  is  maintained  by  an  assist- 
ant, the  surgeon  manipulates  the  thigh  in  order  to  learn  with 
what  ease  or  difficulty  the  fragments  may  be  held  in  position. 
In  adults  in  fracture  of  the  middle  of  the  shaft  of  the  femur 
traction  and  immobilization  are  best  maintained  by  a  modified 
Buck's  extension  apparatus.  Materials  needed  for  a  modified 
Buck's  extension:  Two  strips  of  adhesive  plaster,  each  two  inches 
wide  and  long  enough  to  extend  from  the  seat  of  fracture  to  the 


30I 


302 


FRACTURES    OK    THE    FEMUR 


iiUernal  malleolus.  Surgeon's  adhesive  plaster  is  nonirritating 
to  the  skin,  and  is  prepared  in  rolls  of  convenient  width.  To 
each  strip  of  plaster  at  the  ankle  end  should  be  stitched  a  piece 
of  webbing  the  width  of  the  plaster  and  about  six  inches  long. 
Prepare  five  other  strips  of  adhesive  plaster,  all  of  which  should 
be  one  and  a  half  inches  wide.  Three  of  these  strips  should 
be  long  enough  to  encircle  respectively  the  leg  above  the  mal- 
leoli, the  knee  above  the  condyles,  and  the  thigh  an  inch  below 
the  seat  of  the  fracture.  The  remaining  two  strips  of  plaster 
should  be  long  enough  to  extend  spirally  from  the  malleoli  around 
the  leg  and  thigh  to  the  seat  of  fracture.  Prepare  also  a  roller 
bandage  of  gauze  or  cotton  cloth,  a  curved  or  straight  ham-splint 


Fig.  392. — Pulley  arranged  for  bed. 


properly  padded,  and  three  adhesive  straps  for  holding  the  ham- 
splint. 

In  addition,  three  coaptation  splints  for  surrounding  the  thigh 
are  required,  also  six  webbing  straps  with  buckles  or  strips  of 
bandage  to  be  used  as  straps ;  fresh  sheets  or  pillow-cases  or  towels 
for  padding;  a  swathe,  to  encircle  the  pelvis,  made  of  unbleached 
cotton  cloth  or  medium  weight  Shaker  flannel ;  and  a  long  outside 
splint  of  wood,  four  inches  wide,  to  extend  from  the  axilla  to  six 
inches  below  the  sole  of  the  foot.  To  this  last  a  cross-piece, 
eighteen  inches  long,  should  be  fastened,  making  thus  a  long 
T-splint.  The  Hst  is  completed  by  two  towels  for  perineal  straps, 
safety-pins,  a  pulley,  which  can  be  bought  at  little  cost  at  any 
hardware  store   (see  Fig.   390).     This  pulley  should  be  screwed 


i^racture;  of  shaft  of  femur — TKiiATMENT  303 

into  a  broom-handle  cut  to  the  right  height.  A  block  with  hooks 
above  and  a  pulley  below  will  sometimes  be  found  to  be  more 
convenient  than  the  broom-handle  arrangement  (see  Fig.  392). 
A  spreader  (see  Fig.  393),  which  is  a  piece  of  wood  two  inches 
wide  and  a  little  longer  than  the  width  of  the  foot,  perforated 
at  its  center  for  the  extension  weight  cord.  There  should  be 
provided  a  cord,  three  feet  long,  size  of  a  clothes-line;  two  bricks 
or  wooden  blocks  for  elevating  the  foot  of  the  bed ;  four  sand-bags, 
twenty  inches  long  and  six  inches  wide;  a  cradle  (see  Fig.  394) 


Fig.  393. — Spreader  of  wood  for  preventing  extension  straps  from  chafing  ankle  and  foot. 
Cord  for  attaching  weight. 

to  keep  the  weight  of  the  clothes  from  the  thigh — the  cradle 
may  be  a  chair  tipped  up,  or  barrel-hoops  nailed  together. 

Application  of  the  Modified  Buck's  Extension. — All  the  materials 
being  in  readiness  and  at  hand,  the  patient  having  been  etherized 
and  the  fracture  examined,  the  thigh  and  leg  and  foot  are  first 
washed  with  warm  water  and  Castile  soap  and  thoroughly  dried. 
The  long  straight  strips  of  adhesive  plaster  with  the  webbing 
attached  are  applied  to  the  middle  of  the  two  sides  of  the  leg 
and  thigh  up  to  the  seat  of  fracture.  The  junction  of  the  ad- 
hesive plaster  and  webbing  should  be  brought  to  just  above  the 


304  FRACTURES   OF    THE    FEMUR 

malleoli.  The  two  spiral  and  then  the  three  circular  strips 
should  next  be  applied  as  indicated  (see  Fig.  395).  Over  the 
extension  is  placed  a  roller  bandage,  snuglv  and  evenly  inclosing 
the  foot.  The  bandage  steadies  the  adhesive  plaster,  prevents 
swelling  of  the  foot,  and  affords  comfort.  Then  the  padded 
posterior  coaptation  or  ham-splint  is  applied  and  held  by  three 
straps  of  adhesive  plaster,  one  at  each  end  of  the  splint  and  one 
below  the  knee  (see  Fig.  396).  If  the  curved  ham-splint  is  used, 
the  padding  (one  sheet  of  sheet  wadding)  should  be  laid  upon 
the  splint  evenlv  throughout.  If  a  straight  ham-splint  is  used, 
the  padding  should  be  applied  evenly,  and  at  the  middle  of  the 
ham,  behind  the  knee,  should  be  placed  an  additional  pad  (see 


Fig.  394. — Cradle  to  keep  clothes  from  leg.     Made  from  two  barrel-hoops. 

^ig-  397)  iri  order  to  support  the  knee  in  its  natural  position. 
This  additional  pad  should  be  placed  between  the  splint  and  the 
layer  of  sheet  wadding.  The  tendency  of  the  padding  of  the 
ham-splint  is  to  slip  away  from  each  end  of  the  splint  and  thus 
leave  it  unduly  pressing  into  the  thigh  and  calf.  It  is  wise  to 
hold  this  padding  in  place  by  strips  of  adhesive  plaster  at  each 
end  of  the  splint.  The  three  thigh  coaptation  splints  should 
be  next  put  in  position — one  anteriorly,  extending  the  whole 
length  of  the  thigh  from  groin  to  patella;  one  externally,  extend- 
ing from  trochanter  to  external  condyle;  and  one  internally,  ex- 
tending from  just  below  the  perineum  to  just  above  the  adductor 
tubercle  (see  Fig.  397).  The  best  padding  for  these  splints  is  a 
towel  folded  the  length  of  the  splints  and  placed  evenly  about 


Fig-  395' — Fracture  of  the  thigh.     Adhesive-plaster  extension  strips  ;  long,  upright,  circular, 
and  obliquely  applied  strips. 


Fig.  396. — Fracture  of  the  thigh.     Extension  strips  applied,  covered  by  bandage.     Ham-splint 
applied  ;  two  straps  and  pad  in  ham. 


Fig.  397. — Fracture  of  the  thigh.     Extension  strips  applied.     Cotton  bandage.     Ham-splint, 
straps,  pad,  and  coaptation  splints  about  the  seat  of  fracture.     Straps  and  buckles. 
20  305 


3o6 


FRACTl'RES    OF    THE    FEMUR 


the  thigh  These  sphnts  are  held  by  an  assistant-  while  three 
or  four  straps  are  tightened  sufficiently  to  hold  them  firmly 
in  place.  While  these  coaptation  splints  arc  being  applied  it  is 
very  importafit  that  steady  traction  be  made  upon  the  lower 
fragment  in  order  to  maintain  its  reduction.  The  straps  of  the 
coaptation  splints  are  then  finally  tightened.  The  long  outside 
splint   with  the  T  cross-piece  is  then   padded   with   sheets   and 


Fig.  39S. — FiaLlure  01  ihe  thigh.     Compleled  apparatus  as  in  figure  397,  and  in  addition  a  long 
outside  T-splint,  straps,  and  swathe.     Weights  applied. 


Fig.  399. — Fracture  of   the  thigh.      Completed  apparatus   with  bed  elevated.      The  outside 
splint  is  broad  and  without  the  T  foot-piece.    The  swathe  is  very  snugly  applied. 


applied  to  the  side  of  the  limb  and  the  body  (see  Fig.  398).  The 
upper  end  of  the  splint  is  inclosed  in  a  swathe,  which  passes 
around  the  body  and  is  fastened  with  safety-pins.  The  thigh 
and  leg  are  held  steadily  to  the  outside  splint  by  two  or  three 
straps  (see  Fig.  399).  The  assistant,  making  extension,  exchanges 
his  traction  for  that  of  the  weight  and  pulley.  The  foot  of  the 
bed  is  raised  upon  blocks  or  bricks,  in  order  to  provide  the  counter- 
extension   by   means   of  the   weight   of  the   body.     The   heel   is 


fracture;  of  shaft  of  femur — treatment  307 

protected  from  undue  pressure  by  a  ring.  The  foot  is  kept  at 
a  right  angle  with  the  leg  (see  Fig.'  400).  The  sand-bags  are 
laid  along  the  inner  and  outer  sides  of  the  limb  to  add  greater 
steadiness  to  the  apparatus.  The  cradle  is  placed  over  the 
foot  and  leg. 

Throughout  the  course  of  the  treatment  of  a  fracture  of  the 
thigh  it  is  necessary  to  be  positive  of  four  things :  (a)  The  absence 
of  shortening  in  the  injured  thigh ;  (b)  the  prevention  of  outward 
bowing  of  the  thigh;  (c)  the  prevention  of  permanent  rotation 


Fig.  400. — Form  of  stirrup  to  prevent  the  foot  assuming  an  equinus  position. 


Fig.  401. — Diagram  of  section  of  leg  and  splint  to  show  how  a  strap  carried  from  the  back 
of  the  leg  over  the  long  side-splint  can  prevent  eversion  of  the  foot  and  leg. 


of  the  leg  and  lower  thigh  outward  below  the  seat  of  fracture; 
and  finally  (d),  the  prevention  of  a  sagging  backward  of  the  thigh 
at  the  seat  of  fracture,  causing  what  appears  on  standing  as  a 
false  genu  recurvatum. 

(a)  The  shortening  of  the  injured  leg  is  prevented  bv  a  suffi- 
ciently heavy  weight  for  extension.  This  weight  can  be  ap- 
proximately but  not  accurately  determined.  Ordinarily,  in 
an  adult  fifteen  or  twenty  pounds  are  needed  to  hold  the  frag- 
ments  in   proper   position.     Comparative    measurement    of   the 


^o8 


FRACTrRES    OF    THE    FEMUR 


legs  from  the  anterior  superior  spinous  process  to  the  malleolus 
should  be  made  regularly  every  other  day,  and  the  measurements 
recorded  during  the  first  two  weeks  of  immobilization  and  the 
extension  weight  correspondingly  adjusted. 

(b)  In  order  to  prevent  any  outward  bowing  of  the  thigh,  the 
thigh  and  leg  should  be  slightly  abducted  after  the  apparatus 
is  applied,  so  that  the  extension  is  made  with  the  limb  in  this 
abducted  position  (see  Fig.  40,^). 

(c)  In  order  to  prevent  thigh  from  rotating  outward  below 


Fig.  402. — The  more  usual  deformities  in  fracture  of  the  shaft  of  the  femur.     Outward  and 

posterior  bowing. 


the  fracture  and  thus  carrying  the  leg  and  foot  with  it, — to  pre- 
vent, in  other  words,  eversion  of  the  foot, — a  bandage  six  inches 
wide  should  be  fastened  by  pins  below  the  calf  of  the  leg  to  the 
posterior  part  of  the  bandage  or  ham-splint,  and  brought  up  on 
the  outer  side  of  the  leg  and  fastened  to  the  long  outside  splint 
or  to  the  cradle  above.  The  leg  meanwhile  is  held  in  the  cor- 
rected position.  If  this  bandage  is  fastened  to  the  cradle,  the 
latter  should  be  fastened  firmly  to  the  bed. 

(d)  The  sagging  backward  of  the  thigh   (see  Fig.  402)  is  pre- 


SUBTROCHANTERIC    FRACTURE 


309 


vented  by  the  posterior  coaptation  splint  and  its  proper  padding. 
(See  Supracondyloid  Fracture  of  the  Femur. ) 

Subtrochanteric   Fracture   of   the   Shaft   of   the   Femur. — 
Fractures   of   the   upper   third   of   the   shaft   are   comparatively 


Fig.  403. — Showing  the  necessity  of  ab- 
ducting the  injured  leg  in  thigh  fracture.  In 
dotted  line  is  shown  the  position  likely  to  re- 
sult fiom  neglect  of  this  abduction. 


Fig.  404. — Action  of  the  muscular 
pull  of  the  iliopsoas  and  of  the  external 
rotators  in  producing  deformity  in  frac- 
ture of  the  femur  high  up.  Upper  frag- 
ment is  flexed  and  abducted  upon  the 
trunk. 


rare.  The  diagnosis  of  this  fracture  is  not  ordinarily  difficult. 
The  displacement  is  characteristic:  The  upper  fragment  is  flexed 
and  abducted,  and  the  lower  fragment  overrides  the  upper  one 
and    is   slightly   adducted.     The   treatment    should    restore   the 


3IO 


FRACTURES    OF    Tllli    FH.MUR 


line  of  the  thigh.  At  times  the  ordinary  extension  and  counter- 
extension,  as  for  a  fracture  of  the  middle  of  the  femur,  may 
prove  effective..  If  it  is  not  efTective, — and  it  usuallv  is  not, — 
the  leg  and  lower  fragment  should  be  elevated  upon  an  inclined 
j)lane,  so  as  to  bring  the  lower  fragment  up  to  the  upper  one, 
for  it  will  be  found  impossible  to  lower  the  upper  fragment. 
Traction  should  then  be  made  in  the  line  of  the  elevated  thigh 
from  above  the  condyles  of  the  femur.      If  position  and  traction 


Fig.  405. — Case:  Oblique  subtroclianteric  fracture 
of  shaft  of  femur  (X-ray  tracing). 


Fig.  406. — Spiral  fracture  of  the 
shaft  of  the  femur  high  up  (X-ray 
tracing). 


are    inefficient, — and    they    usually    are, — then    suturing   of    the 
fragments  should  be  contemplated. 

It  will  be  found  impossible  to  correct  completely  the  ordinary 
deformity  of  abduction  and  flexion  of  the  upper  fragment  and 
adduction  and  riding  up  of  the  lower  fragment  by  traction  upon 
the  lower  fragment,  no  matter  in  what  position  the  lower  frag- 
ment may  be  placed  for  traction.  Rendering  the  closed  frac- 
ture open  by  incision  and  suturing  the  bones  in  position  is  the 
only  possible  way  of  securing  a  perfect  result  either  anatomically 


SUPRACONDYLOID  FRACTURE;  3II 

or  functionally.  The  surgeon  must  be  judicious  in  the  selection 
of  the  patients  upon  whom  he  operates.  Even  though  old,  if 
the  patient  is  in  excellent  general  health,  the  operation  may  be 
done  with  every  prospect  of  success. 

Supracondyloid  Fracture  of  the  Femur. — The  deformity 
is  characteristic  and  fairly  typical  (see  Fig.  408) ;  displacement 
of  both  fragments  backward  is  sometimes  seen   (see  Fig.  412). 


■pig.   407.— Fractured   femur,   base  of  neck  driven  into  the  shaft.     Spiral   fracture   of  shaft 
just  below  this  (Warren  Museum,  6529). 


The  upper  end  of  the  lower  fragment  is  displaced  backward, 
chiefly  through  the  pull  upon  it  by  the  gastrocnemius  muscle. 
Treatment  of  this  fracture  in  the  straight  and  extended  posi- 
tion is  usually  unsatisfactory.  It  is  necessary  either  to  flex  the 
leg  in  order  to  relax  the  gastrocnemius  muscle  or  to  do  a  tenot- 
omy upon  the  tendo  Achillis.  One  of  these  procedures  having 
been  carried  out,  the  thigh  and  leg  should  then  be  placed  upon  a 


312 


FRACTURES    i)F    THE    FEMUR 


double  inclined  plane.  Pressure  by  pads  may  be  exerted  upon 
the  upper  end  of  the  lower  fragment  in  order  to  lift  it  forward 
into  apposition  with  the  upper  fragment.  Slight  traction,  if 
possible,  should  be  maintained  upon  the  lower  fragment.  Re- 
peated examinations  with  the  fluoroscope  will  indicate  when 
reduction  is  completed. 

The  After-treatment  and  Prognosis  of  Fracture  of  the 
Thigh. — Inspection  of  the  fractured  limb  should  be  made  at 
least  daily.  Measurement  should  be  made  twice  a  week  during 
the  first  few  weeks,  the  internal  malleolus  being  reached  through 
the  bandage.  Parts  of  the  apparatus  may  need  changing,  and 
straps  may  require  tightening  or  loosening.     The  heel  and  sacrum 


Shaft  of  femur. 


Condyles  and  lower  frag- 
ment of  femur. 


Patella. 


/ Tibi: 


Fig.  408. — Low  fracture  of  the  shaft  of  the  femur.  Displacement  of  the  lower  fragment 
backward  by  the  gastrocnemius  muscle,  and  of  the  upper  fragment  forward.  Overlapping  of 
fragments  (X-ray  tracing). 


will    require    attention    because    of   the   constant    pressure    from 
lying  in  one  position. 

Ordinarily,  there  will  be  little  or  no  pain  associated  with  the 
repair  of  the  fracture.  After  about  four  weeks  all  apparatus 
should  be  removed  and  the  limb  thoroughly  inspected,  to  de- 
tect, if  possible,  any  uncorrected  deformity,  and  to  determine 
whether  union  is  yet  firm.  In  from  four  to  six  weeks  repair  in  a 
healthy  child  or  young  adult  should  have  advanced  to  the  stage 
of  firm  union.  The  apparatus  should  then  be  reapplied.  At 
the  end  of  the  eighth  week  all  apparatus  should  be  finally  re- 
moved. The  thigh  should  be  washed  and  thoroughly  oiled. 
The  patient  should  be  permitted  to  lie  in  any  position  in  bed 


SUPRACONDYLOID    FRACTURE 


313 


without  retentive  apparatus  for  one  week.  After  the  spHnts 
are  first  left  off  and  while  the  patient  is  still  in  bed  daily  systematic 
massage  to  the  whole  limb  should  be  practised,  together  with 
slight  passive  and  active  motion  at  the  knee-joint.  The  patient 
should  not  be  allowed  to  bear  weight  upon  the  unprotected  thigh 
until  after  the  ninth  week.  At  the  ninth  week  he  should  be 
allowed  up  and  about  with  crutches,  and  a  moderately  high- 
soled  shoe  (two  inches)  should  be  worn  upon  the  foot  of  the  un- 
injured thigh.     He  should  bear  no  weight  upon  the  injured  leg. 


Fig.  409. — Lateral  view.  Oblique  fracture  of  the  shaft  of  the  femur  low  down.  Little 
backward  displacement  of  lower  fragment.  Considerable  shortening  of  thigh  from  forward 
displacement  of  upper  fragment.     Man  aged  forty.     Recovery  (X-ray  tracing). 


The  seat  of  the  fracture  should  be  protected  bv  coaptation  splints 
and  straps  and  a  light  spica  plaster-of- Paris  bandage  from  the 
toes  to  above  the  waist.  At  the  end  of  twelve  weeks  all  support 
may  be  discarded.  Of  course,  fractures  of  the  femur  vary  con- 
siderably in  the  time  the  patient  is  able  to  get  about,  but  the 
foregoing  routine  is  that  of  average  uncomplicated  cases. 

It  is  very  probable  that  massage  without  any  passive  motion, 
as  early  as  the  second  week,  to  the  region  of  the  knee  and  thigh, 
will    prevent    much    of   the   knee-joint    disability   and    muscular 


'4 


FRACTTRES    OK    THE    FEMUR 


atrophy  that  so  often  hinder  convalescence  in  these  cases.  It 
is  very  important  also,  in  order  to  gain  this  end,  to  see  that  the 
extension  is  made  from  around  and  above  the  condyles  of  the 
femur  and  not,  as  so  often  happens,  from  the  knee-joint  itself. 
It  ought  to  be  possible  to  avoid  all  knee-joint  stiffness  bv  the 
judicious  use  of  massage  to  the  whole  limb  and  passive  motion 
to  the  knee-joint.  These  measures  in  many  cases  should  be 
instituted  and  practised  regularly  and  persistently  and  always 
cautiously  from  the  second  week  after  the  injury. 


\ 


Fig.  410. — Same  as  figure  409.     Anteroposterior  view  (X-ray  tracing). 


The  ambulatory  treatment  of  fracture  of  the  thigh  by  means  of 
the  long  Taylor  hip  traction  splint,  a  high  sole  upon  the  shoe  worn 
on  the  well  foot,  and  crutches,  is  of  very  great  value,  especially 
in  children  and  young  adults.  The  hip-splint,  consisting  of  a 
long  outside  upright,  pelvic,  thigh,  and  calf  bands,  is  applied 
v/ith  two  perineal  straps  (see  Figs.  414,  415).  The  traction  is 
made  through  the  windlass  at  the  foot-piece  after  fastening  the 
extension  strips  to  it.  The  countertraction  is  made  by  the  two 
perineal  straps.  The  thigh  is  securely  held  by  coaptation  splints 
and  a  bandage  about  the  thigh  and  sphnt.     The  patient  goes 


PROGNOSIS  315 

about  with  crutches  and  a  high  sole  of  two  inches  upon  the  shoe 
worn  on  the  well  foot,  bearing  a  little  weight  upon  the  foot  of 
the  splint.  As  a  matter  of  fact,  the  real  value  of  this  method 
in  fracture  of  the  thigh  lies  in  the  improvement  to  the  general 
health  by  the  early  getting  into  the  upright  position  and  out 
of  bed.  This  application  of  the  ambulatory  method  certainly 
is  of  great  comfort  to  the  patient.     That  it  hastens  the  repara- 


Fig.  411. — Oblique  fracture  of  the  shaft  just  above  the  knee,  with  spUtting  apart  of  the  two 
condyles.  Extreme  displacement ;  necrosis  of  tip  of  upper  fragment.  Patient,  a  man  of  thirty- 
seven  years,  lived  for  five  months  (Warren  Museum,  specimen  1118). 


tive  process  is  yet  to  be  fully  demonstrated.  If  the  Taylor  hip- 
splint  is  used,  it  should  be  applied  when  union  is  found  to  be 
firm.  After  wearing  the  splint  in  bed  for  a  few  days  the  patient 
may  get  up  and  be  about. 

The  Prognosis. — What  shall  be  considered  a  satisfactory 
result  in  the  treatment  of  a  closed  fracture  of  the  shaft  of  the 
femur?     The  degree  of  restoration  of  function  can  not  be  deter- 


3i6 


FRACTURES    OF    THE    FEMUR 


mined  with  accuracy  until  about  one  year  has  elapsed  after 
treatment  is  suspended.  The  following  six  requisites  for  a  satis- 
factory result  following  fracture  of  the  femur  are  those  reported 
bv  a  committee  from  the  American  .Surgical  Association,  and 
generally  accepted  as  forming  a  good  working  basis. 

For  a  result  to  rank  as  a  good  one,  it  must  be  established 
that  firm  bony  union  exists ;  that  the  long  axis  of  the  lower  frag- 
ment is  either  directly  continuous  with  that  of  the  upper  frag- 
ment or  is  on  nearly  parallel  lines,  thus  preventing  angular 
deformity;  that  the  anterior  surface  of  the  lower  fragment  main- 
tains nearly  its  normal  relation  to  the  plane  of  the  upper  frag- 
ment,   thus   preventing   undue   deviation    of   the   foot   from   its 


Upper  fragment  of  femur. 


Lower  fragment  of  femur. ■* 


Fig.  412.— Transverse  fracture  of  the  femur  in  the  lower  third  with  backward  displacement, 
of  both  fragments.     Lateral  view  (X-ray  tracing). 


normal  position;  that  the  length  of  the  Hmb  is  exactly  equal  to- 
its  fellow  or  that  the  amount  of  shortening  falls  within  the  limits 
found  to  exist  in  ninety  per  cent,  of  healthy  Hmbs — namely, 
from  one-eighth  to  one  inch;  that  lameness,  if  present,  is  not  due 
to  more  than  one  inch  of  shortening;  that  the  conditions  attending 
the  treatment  prevent  other  results  than  those  obtained. 

Results  After  Fracture  of  the  Thigh. — The  prognosis  as  to 
the  usefulness  of  the  thigh  after  fracture  deduced  from  the  sta- 
tistics available  is  of  little  value,  because  the  details  of  the  cases 
are  not  presented  nor  is  any  discrimination  made  between  the 
seats  of  fracture  and  the  ages  of  the  patients.  Realizing  these 
facts,  I  have  very  carefully  examined  and  classified  the  final 
results  several   vears  after  treatment  had   ceased   in  thirty-five 


PROGNOSIS 


317 


cases  of  uncomplicated  fracture  of  the  shaft  of  the  femur  treated 
at  the  Massachusetts  General  Hospital.  The  treatment  in  all 
cases  was  practically  the  same:  a  Buck's  extension  with  outside 
T-splint,  or  a  long  Desault  apparatus,  and,  toward  the  end  of 
treatment,  a  plaster  spica  of  the  thigh,  groin,  and  trunk,  with 
crutches.  Even  though  this  number  of  cases  is  relatively  small, 
yet,  after  having  most  carefully  analyzed  them,  it  seems  highly 
probable  that  even  if  this  number  should  be  increased,  the 
ultimate  results  would  not  materially  differ.  These  thirty-five 
cases  have  been  arranged  in  three  groups,  according  to  age:  (a) 
Those  of  childhood;  (b)  those  of  adult  life;  and  (c)  those  of  old 
age.  (a)  Fourteen  cases  occurred  in  childhood,  the  ages  aver- 
aging seven  and  a  half  years.     Patients  were  heard  from  or  re- 


--  Upper  fragment. 


—  Lower  fragment. 


\ 

Fig.  413.— Same  as  figure  412.     Anteroposterior  view,  showing  lateral  displacement. 


ported  for  examination  one  and  a  half  to  seven  years  after  the 
original  injury.  All  cases  were  treated  by  bed  extension,  coap- 
tation splints,  and  the  plaster  spica  to  thigh  and  hip.  All  have 
perfect  functional  results.  Four  cases  mention  slight  pain 
occasionally.  Three  of  these  four  cases  have  a  little  stiffness 
of  the  knee  upon  the  injured  side  one  and  a  half  years  after 
the  accident,  three  and  a  half,  and  three  years  respectively. 
(b)  Sixteen  cases  occurred  in  adults  whose  ages  ranged  from 
eighteen  to  forty-eight  years.  These  were  seen  or  reported  from 
one  to  six  years  after  the  original  injury.  Five  of  these  have 
unqualifiedly  perfect  results,  without  pain  or  stiffness.  The 
remaining  eleven  cases  have  limited  knee-joint  movements, 
aching  in  the  thigh,  pain  after  exercising,  pain  in  wet  weather. 
weakness   in    the    whole   leg,    and    slight    lameness    in    walking. 


;i8 


FKACTl-RKS    UF    THE    KHMUR 


(c)  Five  cases  occurred  during  ohl  age.  The  patients  averaged 
fiftv-eight  vears.  These  were  seen  or  reported  from  two  to  six 
vears  after  the  original  injury.  None  has  functionally  perfect 
results.  There  is  one  case  of  nonunion  of  the  thigh  with  shorten- 
ing of  the  limb.  Two  cases  must  use  a  cane  in  walking.  The 
knee  is  painful  and  motion  is  limited  in  all  cases.     Swelling  of 


Fig.  414. — Fracture  of  the  llii.L;h.  Con- 
valescent ambulatory  splint  without  trac- 
tion. 


Fig.  415. — Fracture  of  the  tliij^li.  Con- 
valescent ambulatory  splint  witliout  trac- 
tion. Coaptation  splints  may  be  api)lied  to 
the  thigh  and  held  by  straps  enclosing  the 
thigh. 


the  leg  is  not  uncommon,  and  pain  in  wet  weather  is  very  com- 
monly complained  of  by  these  old  people. 

Considering  these  reported  cases  individually  and  grouped 
according  to  the  three  age  periods,  it  seems  reasonable  to  con- 
clude that  they  form  a  basis  for  a  fairly  accurate  judgment  as 
to  the  probable  outcome  of  these  injuries  to  the  shaft  of  the 
femur.     As  the  age  increases  the  liability  to  impairment  of  the 


fracture;  of  the  thigh  in  childhood  319 

function  of  the  limb  increases.     This  habiHty  is  very  great  after 
fifty  years  are  passed. 

It  is  not  very  uncommon,  even  in  closed  fractures  of  the  femur, 
to  find  gangrene  of  the  leg  developing  because  of  laceration  or 
pressure  upon  the  great  vessels  of  the  limb.  Early  amputation 
of  the  thigh  just  above  the  fracture  will  be  necessary  in  these 
cases.     It  should  be  done  early  in  order  to  save  life.     In  the  aged 


Fig.  416. — Fracture  of  the  left  thigh  at  the  middle.    Union  solid.     Convalescence  hastened  by 
use  of  hip  splint  with  fixation  of  thigh  by  coaptation  splints  and  straps. 


the  shock  of  the  accident  may  prove  fatal.  In  open  fractures 
the  violence,  usually  direct,  has  been  so  great  that  the  soft  parts 
about  the  knee  and  throughout  the  whole  thigh  have  been  greatly 
torn  and  lacerated  on  either  side  of  the  fractured  bone.  The  shock 
in  these  cases  is  severe.     Recovery  is  always  doubtful. 

Fracture  of  the  Thigh  in  Childhood. — This  is  usually  caused 
by    direct    violence.     The    fracture    is    often    incomplete.     The 


320 


FRACTL'RES    OF    THE    FEMl'R 


D 


symptoms  are  those  of  the  same  fracture'  in  the  aduk.  The 
effusion  into  the  knee-joint  is  seen  perhaps  more  uniformh-  than 
in  the  adult.  This  effusion  disappears  from  the  child's  knee-joint 
more  quickly  than  from  the  adult  knee-joint. 

Treatment. — After  reducing  the  fracture, — making  the  in- 
complete fracture  complete  if  perfect  reduction  can  not  be  ac- 
complished in  any  other  way, — the  problem  of  maintaining 
the  reduction  arises. 

In  children  of  ten  years  and   older  it   is  possible  to  use   the 
Buck's  extension.     A  plaster-of- Paris  spica  splint  from  the  calf 
of    the    leg    to    the    axilla    is  also  a   possible 
method  of  immobilization. 

The  plaster-of- Paris  spica  is  most  efficient  in 
fractures  seen  immediately  after  the  trauma 
and  in  those  in  which  little  or  no  swelling  has 
occurred  and  unattended  by  great  displace- 
ment. After  the  plaster  splint  has  been  applied 
for  ten  davs  it  should  be  removed,  the  limb 
thoroughly  examined,  and  a  new  plaster  splint 
applied  after  correcting  any  existing  deformi- 
ties. 

In  children  under  ten  years  of  age  the  Cabot 
posterior  wire  frame  with  coaptation  splints 
and  extension  is  a  good  method  of  conveniently 
and  efficiently  treating  a  fractured  thigh  or 
fractured  hip. 

The  Cabot  Posterior  Wire  Splint  (see  Fig. 
417):  The  splint  consists  of  two  portions — a 
body  part  and  a  leg  part.  The  patient  lies  upon  the  body 
part  with  the  thigh  and  leg  resting  upon  the  leg  part,  as 
upon  a  coaptation  splint.  Having  a  vise  and  simple  iron 
wire  the  size  of  an  ordinary  lead-pencil,  this  splint  can  be 
made  in  a  few  moments;  the  bending  of  the  wire  according 
to  the  diagram  and  fastening  the  free  ends  by  a  strip  of  small- 
sized  wire  being  all  that  are  required.  It  is  necessary  to  make 
the  following  measurements  before  bending  the  wire  to  the 
general  shape  shown  in  the  diagram — namely,  D  E,  the  distance 
from  the  axilla  to  the  calf  of  the  leg;  A  D,  the  width  of  the  trunk; 


F      E 
Fig.    417. — Cabot 
wire  splint  for  fracture 
of  the  hip  and  thigh. 


TREATMENT    IN    CHILDHOOD 


321 


A  B,  from  the  axilla  to  a  point  midway  between  the  crest  of  the 
ilium  and  the  top  of  the  great  trochanter;  F  E,  the  width  of  the 
leg,  usually  from  two  to  two  and  a  half  inches.  A  D  and  B  C 
are  bent  to  the  curve  of  the  back.     B  C  is  so  bent  that  it  jumps 


Fig.  418.— The   Cabot  wire   splint   ready  for   use.     Lateral  view,  showing   curves  of  splint 
corresponding  to  small  of  back,  buttock,  and  knee. 


"Fig.  419.— The  Cabot  wire  splint  ready  for  use.     Front  view,  showing  covering  of   Canton 
flannel  and  Canton-flannel  double  swathe  for  fixation  to  chest. 


over  the  sacrum  and  does  not  touch  posteriorly  excepting  at 
B  and  C.  The  long  rods  are  so  bent  as  to  adapt  them  to  the 
posterior  curves  of  the  buttock,  thigh,  popliteal  space,  and  leg 
(see  Fig.  418).     The  splint  is  covered,  as  in  the  posterior  wire 


322 


FRACTrRKS    OF    THE    FEMUR 


splint  for  tlie  leg,  bv  layers  of  sheet  wadding  and  eotton  ban- 
dages. A  swathe  is  attached  to  the  two  sides  A  B  and  D  H  of  the 
body  part  (see  Figs.  417  and  419).  The  child  is  carefully  laid 
upon  this  splint,  the  body  swathes  adjusted,  the  extension  strips 
applied,  traction  made  by  weight  and  pulley  with  the  foot  of  the 
bed  elevated,  coaptation  splints  applied  and  held  in  position 
by  straps  that  include  the  posterior  wire  splint.  If  it  is  necessary 
to  move  the  child  for  the  making  of  the  bed,  for  the  use  of  the 
bed-pan,  or  for  bathing,  the  extension  may  be  unfastened  tem- 
porarily without  any  injury  to  the  fracture,  particularly  if  the 
coaptation  splints  are  then  temporarily  tightened  to  secure  a 
firmer  hold  on  the  thigh.  The  child  should  be,  of  course,  clean 
from  both  urine  and  feces,  and  the  fracture  immobilized. 

After  four  weeks  of  bed-treatment  the  child  may  be  up,  with 


Fig.  420. — Bradford  bed-frame  for  fixation  of  trunk  in  fracture  of  the  thigh. 


crutches  and  a  high  shoe  with  the  Cabot  splint  applied.  vShoulder- 
straps  should  be  attached  to  the  splint  when  it  is  worn  in  the 
erect  position.  This  is  one  of  the  simplest,  cleanest,  and  most 
efficient  methods  of  treating  fracture  of  the  thigh  in  young  chil- 
dren. The  child  can  be  moved  with  freedom  and  without  pain. 
A  light  plaster-of- Paris  spica  bandage  may  be  used  in  conva- 
lescence with  crutches  and  a  high  shoe  on  the  uninjured  side. 
In  very  small  children  it  is  sometimes  wise  to  use  the  Brad- 
ford (see  Fig.  420)  frame  and  vertical  suspension  (see  Fig.  421) 
of  one  or  both  thighs.  This  is  an  efificient,  comfortable,  and 
clean  method  of  treatment.  The  Bradford  frame  is  an  iron, 
frame-like  stretcher,  on  which  the  child  lies  and  to  which  the 
shoulders  and  hips  are  fastened  to  prevent  the  child's  moving 
about.  Counterextension  is  then  secured  by  the  immobiliza- 
tion  of   the   pelvis   and   hip.     The   extension   is   applied   to   the 


TREATMENT    IN    CHILDHOOD 


323 


thigh  and  leg  as  usual.  The  limb  is  flexed  on  the  body  to  a 
right  angle,  coaptation  splints  being  applied  to  the  thigh.  After 
the  novelty  of  the  position  passes  away,  the  child  is  perfectly 
contented.  As  soon  as  union  is  firm,  the  permanent  plaster 
spica  dressing  may  be  applied,  and  the  patient  may  be  up  and 
about  with  high  shoe  upon  the  well  foot  and  with  crutches.  The 
use  of  the  long  hip-splint  will  be  of  great  service  in  these  cases 
either  with  or  without  the  extension  foot-piece  (see  Figs.  414, 
415).     After  fracture  of  the  shaft  of  the  femur  in  children  there 


Fig.  421. — Fracture  of  the  femur  in  a  child.  Note  Biadfoul  frame  on  which  child  rests, 
the  position  of  the  lower  extremity.  Shoulders  and  trunk  of  child  held  fixed  by  straps  and 
swathe.  Note  coaptation  splints,  extension,  weight,  and  pulley.  A  comfortable  position  for 
child.     An  efficient  method  of  treatment. 


should  be  no  shortening  and  no  special  difficulty  in  convalescence. 
It  is  wise  to  guard  the  thigh  a  suflficient  time  after  union  is  firm 
to  insure  absolute  solidity  and  freedom  from  bowing  in  anv 
direction  (see  Fig.  423). 

The  Making  of  the  Bradford  Frame. — It  is  most  easily  made 
from  f-  to  ^-inch  gas  piping.  It  should  be  one  inch  wider  than 
the  width  of  the  hips,  and  six  inches  longer  than  the  height  of 
the  child.  It  should  be  covered  with  canvas,  so  as  to  leave  a. 
space  under  the  buttocks  for  the  use  of  the  bed-pan. 


324 


FRACTURES    OF    THE    FEMUR 


SEPARATION  OF  THE  LOWER  EPIPHYSIS  OF  THE  FEMUR 
Anatomy.— The  lower  epiphysis  of  the  femur  is  the  largest 
of  the  epiphyses.  It  unites  with  the  shaft  of  the  bone  at  or 
about  the  twenty- first  year.  The  epiphysis  includes  the  whole 
of  the  articular  surface  of  the  lower  end  of  the  femur.  The 
points  of  origin  of  the  gastrocncmii  muscles  are  situated  upon 
the  epiphysis;  a  few  fibers  only  arise  from  the  diaphysis.  The 
inner  condylar  line  of  the  femur  is  continuous  with  the  inner 
lip  of  the  linea  aspera,  and  terminates  at  the  adductor  tubercle, 
which  can  be  palpated  upon  the  inner  side  of  the  thigh  near  the 


Fig.  422. — Fracture  of  the  thigh  in  a  child.  Vertical  suspension  as  in  figure  421  has  been 
followed.  After  two  weeks  the  lower  extremity  is  lowered  to  this  position  upon  an  inclined 
plane  before  completely  lowering  to  bed  level.  Inclined  plane  made  of  three  pieces  of  rather 
heavy  wood  for  solidity.  Note  the  extension  in  the  line  of  the  long  axis  of  the  lower 
extremitv. 


knee-joint.  The  upper  and  outer  angle  of  the  trochlear  surface 
of  the  femur  can  be  palpated  best  with  the  knee  flexed.  A  line 
drawn  from  this  angle  of  the  trochlea  to  the  adductor  tubercle 
marks  the  level  of  the  lower  epiphysis  of  the  femur.  In  no 
position  of  the  knee-joint  are  the  bones  in  more  than  partial 
contact.  This  is  one  of  the  superficial  joints  of  the  body.  The 
strength  of  the  joint  lies  in  the  ligaments  and  fasciae  about  it. 
Unlike  the  elbow-  and  hip-joints,  it  does  not  depend  upon  the 
contour  of  the  bones  for  strength.  An  attempt  to  overextend 
and  to  bend  the  knee  laterally  brings  very  great  strain  to  bear 
upon  the  ligaments  that  are  attached  to  the  lower  femoral  epiph- 


SEPARATION    OF    THE    LOWER    EPIPHYSIS 


325 


ysis.  If  this  strain  is  of  sufficient  force,  the  epiphyseal  cartilage 
gives  way,  and  the  epiphysis  separates  from  the  shaft  of  the 
femur.  The  common  cause  of  the  accident  is  the  catching  of 
the  leg  or  thigh  in  the  spokes  of  a  revolving  wheel.  The  accident 
most  often  occurs  to  boys  about  ten  years  old   (see  Figs.  424, 

425)- 

The  epiphysis  usually  separates  without  splintering  the  diaph- 
ysis.     The  periosteum  is   stripped   for  a  considerable   distance. 


Fig.  423. — Old  fracture  of  the  thigh  with  deformity.     Due  to  use  of  unprotected  tliigh  before 
complete  consolidation  of  fracture  (Warren). 


About  half  the  cases  are  open,  the  end  of  the  diaphysis  projecting 
through  the  skin  of  the  popliteal  space.  The  knee-joint  is  usually 
unopened.  There  may  be  almost  no  displacement  of  the  frag- 
ments. A  lateral  sliding  of  the  epiphysis  has  often  been  observed. 
One  condyle  has  been  found  in  the  popliteal  space,  but  com- 
monly the  epiphysis  lies  in  front  of  the  shaft  of  the  femur  with 
its  separated  surface  in  contact  with  the  shaft  (see  Figs.  426, 
427,    428).     The    diaphysis    is    displaced    backward    and    down- 


326 


FRACTURES    OF    THE    FEMUR 


Avard  inlo  the  popliteal  space,  because  of  the  possible  high  at- 
tachment of  the  gastrocnemii  and  the  fracturing  force.  The 
nerves  of  this  region  may  be  pressed  upon  or  lacerated,  and  this 
may  be  the  cause  of  great  pain  attending  the  accident.  The 
pophteal  vessels  may  be  compressed,  stretched,  or  even  ruptured. 
Consequently,  interference  with  the  circulation  may  result. 
This  may  be  moderate  and  temporary,   or  extreme  and  result 


Fig.  424.— Case :  Bo^-,  eleven  years  of  age.  Separation  of  the  lower  femoral  epiphysis. 
Photograph  taken  four  hours  after  the  injury.  Note  inversion  of  the  limb;  fullness  of  lower 
third  of  thigh  posteriorly  ;  fullness  over  head  of  tibia  ;  fullness  in  popliteal  space  (X-ray 
tracing,  Fig.  426,  e.xplains  the  evident  deformity). 


Fig.  425.— Case  same  as  figure  424.     Separation  of  the  lower  femoral  epiphysis  of  the  left  leg. 
Contrast  two  knees  (see  X-ray  tracing,  Fig.  426). 


in  gangrene  of  the  leg.  The  shock  attending  this  accident  is 
often  great.  vSuppuration  may  appear  in  closed  separations, 
although  it  is  infrequent ;  it  is  much  more  likely  to  appear  in 
open  lesions.  .Sloughing  of  the  skin  is  not  unusual  from  the  bony 
pressure.  Gangrene  of  the  leg  sometimes  occurs.  Necrosis 
of  bone  is  not  unlikely  to  result,  particularly  if  the  separation 
of  the  periosteum  is  great  (see  Fig.  429). 

Diagnosis. — After  severe  trauma  to  the   region  of  the  knee 


SEPARATION    OF    THii    L0WP:R    IvPIPHYSIS 


327 


there  are  three  injuries  that  should  be  eonsidered  possible :  a 
dislocation  of  the  knee-joint,  a  supracondyloid  fracture  of  the 
femur,  or  a  separation  of  the  lower  epiphysis  of  the  femur. 

There  may  be  so  much  swelling  that  a  satisfactory  examination 
is  impossible.  Ordinarily,  careful  palpation  will  detect  the  bony 
outlines  of  a  dislocation.  This  is  extremely  rare  in  children. 
The  crepitus  of  a  supracondyloid  fracture  is  bony  and  hard,  and 
the  displacement  of  the  distal  fragment  into  the  popliteal  space 
evident.     All  fractures  at  the  knee  are  not  necessarily  supra- 


Diaphysis  of  femur. 


Lower  femoral 
epiphysis. 

Patella. 


—  Condyle  of  femur. 


Upper  epiphysis 
of  tibia. 


— -  Diaphysis  of  tibia. 
■  —  -  Fibula. 


Fig.  426. — Lateral  view.  Case  of  figure  424.  Boy,  aged  eleven  years.  Separation  of  the 
lower  femoral  epipliysis.  Displacement  forward  of  epiphysis  and  backward  of  lower  end  of 
shaft  (see  Figs.  424,  425.     X-ray  tracing). 


condyloid.  Several  cases  of  fracture  of  one  condyle  of  the  femur 
into  the  joint  are  reported.  The  separated  epiphysis  itself 
may  be  split  through  into  the  joint.  A  severe  trauma  to  the 
knee,  a  cart-wheel  accident  to  a  young  boy,  attended  by  con- 
siderable shock,  followed  by  great  swelling  of  the  knee,  a  fullness 
in  the  popliteal  space,  feeble  or  absent  pulsation  in  the  dorsalis 
pedis  and  posterior  tibial  arteries,  increased  lateral  and  antero- 
posterior mobility  at  the  knee,  and  soft  crepitus  form  the  picture 
characteristic  of  a  separation  of  the  lower  femoral  epiphysis. 
Prognosis. — It  is  impossible  to  state  positively  that  in  any 


32} 


FRACTURES    OF    THE    FEMUR 


given  case  there  will  or  will  not  be  shortening  of  the  leg  upon 
the  injured  side  because  of  a  cessation  of  growth  in  the  femoral 
epiphysis.     If  the  epiphysis  is  separated   without  great  lacera- 


Epiphyseal  line. 
Lower  femoral  epiiiliysis. 


Epiphyseal  line  of  tibia. 
Epiphyseal  line  of  fibula. 


Fig.  427. — Same  case  as  figure  426.  Aiiteroposlerior  view  of  uninjured  knee  in  a  child  eleven 
years  of  age,  showing  epiphysis  in  position  (X-ray  tracing). 


Lower  femoral  epiphysis. 

Epiphyseal  line  of  tibia. 
Epiphyseal  line  of  fibula. 


Fig.  428. — Same  case  as  figure  426.    Anteroposterior  view  of  displaced  lower  femoral  epiphysis 
in  a  boy  eleven  years  old. 


tion  and  periosteal  denudation  and  is  replaced  soon  after  the 
injury,  the  chances  are  that  there  will  be  a  minimum  amount 
of  shortening  of  the  affected  leg.     After  open  incision  and  re- 


SEPARATION   OF   THE   LOWER    EPIPHYSIS 


329 


placing  of  the  epiphysis  in  closed  fractures  good  results  are  to  be 
expected  as  far  as  the  usefulness  of  the  joint  is  concerned.  Slight 
necrosis  of  bone  may  attend  convalescence.  If  the  separation 
is  closed  and  reduction  is  impossible  by  manipulation  alone,  open 
incision  should  be  made. 

Treatment. — If  the  vessels  are  torn ;  if  there  is  great  laceration 
of  the  soft  parts,  amputation  should  be  performed.  If  the  sepa- 
ration is  open  and  the  shaft  of  the  femur  protrudes  through  the 
wound,  and  much  of  the  diaphysis  is  seen  to  be  denuded  of  perios- 

Lower  femoral  epiphysis. 

/' 

/■ 

/ 


Patella. 


Diaphysis  of  femur. — 


Upper  epiphysis  of 

tibia. 


Diaphysis  of  tibia. 


Fig.  429. — Separation  of  lower  epiphysis  of  the  femur  with  displacement  forward  and  upward 
between  femoral  diaphysis  and  patella  (Warren  Museum,  S116-1). 


teum,  the  diaphysis  should  be  resected  to  the  limit  of  periosteal 
separation,  and  then  the  bone  reduced.  It  may  be  necessary  to 
enlarge  the  opening  in  the  soft  parts  before  it  is  possible  to  reduce 
the  bone.  If  the  separation  is  closed,  reduction  by  manipulation 
should  be  attempted;  if  successful,  the  leg  should  be  flexed  to  a 
right  angle  or  an  acute  angle  and  immobilized  in  a  plaster-of- 
Paris  splint. 

The  pressure  downward  is  upon  the  edge  of  the  displaced 
epiphysis  at  the  point  indicated  by  the  line  pointing  to  the  "lower 
femoral  epiphysis"  in  the  figure. 


330 


FRACTl'RKS    OF    THE    FEMUR 


Reduction  by  Manipulation  When  the  fragment  is  Displaced 
Forward. — While  an  assistant  makes  traction  upon  the  leg,  the 
surgeon,  grasping  the  thigh  above  the  condyles  with  the  fingers  in 
the  popliteal  space,  making  pressure  on  the  upper  fragment,  pushes 
with  his  two  thumbs  upon  the  upper  border  of  the  displaced 
epiphysis  (see  Fig.  426).  The  pressure  downward  is  upon  the 
edge  of  the  displaced  epiphysis  at  the  point  indicated  by  the  line 
pointing  to  the  "lower  femoral  epiphysis"  in  the  figure.    The  leg  is 


Fig.  430. — Diagram  to  show  method  of  reduction  of  separated  femoral  epiphysis  by  incision. 
Retractors  are  upon  diaphysis  and  epiphysis,  and  lines  of  traction  are  shown  by  arrows. 


Fig.  431. — Cabot  splint  arranged  as  double  inclined  plane  for  epiphyseal  separation  at  the 
lower  end  of  femur.  £,  The  part  behind  the  knee-joint,  may  be  bent  to  a  more  acute  angle; 
C,  the  body  portion,  is  to  be  molded  to  the  trunk  ;  A,  the  foot-piece.  With  the  angle  at  B 
obliterated,  the  splint  may  be  used  for  fracture  of  the  leg  in  childhood. 


gradually  flexed.  If  the  reduction  is  achieved,  a  soft  grating  sen- 
sation will  have  been  felt,  and  the  shortening  of  the  leg  that  ex- 
isted previous  to  reduction  will  disappear.  The  contour  of  the 
knee  will  assume  a  somewhat  normal  appearance. 

The  Operative  Method  of  Reduction. — The  obstacle  to  reduction 
is  no  single  band  or  obstruction,  it  is  the  retraction  and  tension 
maintained  bv  the  fasciae,  ligaments,  and  muscles  of  the  thigh 
upon  the  tibia.     This  retraction  is  so  great  that  the  tibia  is  held 


SEPARATION  OF  the;  lower  EPIPHYSIS  331 

crowded  against  the  lower  end  of  the  upper  fragment,  and  pre- 
vents the  replacing  of  the  epiphysis.  An  incision  is  best  made 
over  the  denuded  shaft  of  the  femur  on  the  outer  side  of  the  leg. 
The  shaft  and  the  epiphysis  are  exposed  in  the  wound.  Traction 
should  be  made  by  means  of  periosteal  retractors  upon  the  epiph- 
ysis, and  countertraction  upon  the  diaphysis  while  the  leg  is  slowly 


Fig.  432. — Separation  of  the  lower  femoral  epiphysis  in  a  boy  fourteen  years  old.  Reduc- 
tion without  operation.  Recovery.  This  X-ray  was  taken  after  recovery.  Before  operation 
the  X-ray  was  similar  to  that  shown  in  Frontispiece  "  C."  Functionally  slight  loss  of  exten- 
sion. 


flexed  from  the  completely  extended  position,  as  indicated  in  the 
figure  (see  Fig.  429).  This  will  result  in  the  reduction  of  the  dis- 
placement. Suture  of  the  bones  may  be  needed  to  retain  the  re- 
placed epiphysis  in  position.  The  flexed  position  of  the  leg  will 
assist  materially  in  retaining  the  fragment  in  position.  The  ap- 
plication of  a  light-weight  plaster-of- Paris  circular  bandage  from 


332 


FRACTURES    OF    THE    FEMUR 


the  toes  to  the  groin,  with  the  leg  flexed  to  a  right  angle,  will  im- 
mobilize the  parts. 

After-union  is  firm  between  the  epiphysis  and  shaft.  After 
three  or  four  weeks  the  leg  mav  be  gradually  extended.  The  foot 
of  the  injured  leg  may  be  touched  to  the  floor  while  the  plaster 
s])lint  is  in  place  about  five  weeks  after  the  injury.  Slight  weight 
may  be  borne  upon  it.  The  plaster  should  be  removed  after  about 
six  weeks,  and  gentle  active  and  passive  motion  made  at  the  knee- 
joint.  Massage  to  the  calf  of  the  leg  and  the  thigh  should  be  given 
daily.     A  flannel  bandage  applied  to  the  foot,  ankle,  leg,  and  thigh 


Fig.  433. — Case  :  Boy,  aged  eleven  years.  Separation  of  left  lower  femoral  epiphysis  ;  in- 
cision, reduction.  Recovery.  After  six  months,  useful  leg.  Knee  motion  in  fle.xion  beyond 
a  right  angle  as  shown  (see  frontispiece  and  Figs.  424-429  inclusive). 


will  be  all  the  support  that  is  needed.  After  about  ten  weeks 
the  boy  should  be  allowed  to  step  on  the  foot  all  he  chooses.  At 
first  he  will  do  this  with  fear,  but  soon  wath  confidence.  There 
will  usually  be  a  little  limitation  of  motion  in  the  knee-joint  (see 

Figs.  433,  434)- 

Traumatic  Gangrene,  Septicemia,  Malignant  Edema. — Fractures 
complicated  with  laceration  of  the  large  vessels  are  a  frequent 
cause  of  gangrene.  If  an  acute  infectious  process  starts  in  a  limb 
with  traumatic  gangrene,  the  gangrene  spreads  with  frightful 
rapiditv.  The  general  disturbance  is  very  great.  A  septicemia 
of  grave  type  results.     To  such  cases  in  which  there  is  much  gas 


SEPARATION    OP    THE    LOWKR    EPIPHYSIS  333 

formation,  associated  with  edema,  and  which  results  in  rapid  de- 
struction of  tissue,  the  name  maHgnant  edema  is  given.  The 
specific  bacillus  of  malignant  edema  will  be  discovered  in  the 
blood  and  tissues  far  above  the  wound  of  the  soft  parts. 

The  proper  treatment  is  early  high  amputation  with  stimulation 
of  the  heart  by  strychnin  and  alcohol. 


Fig.  434. — Case  same  as  that  in  figure  433.  Separation  of  lower  femoral  epiphysis.  Note 
•degree  of  extension  possible  and  cicatrix  of  incision  six  months  after  operation.  Note  also 
absence  of  deformity. 


Fat  Embolism. — Fat  embolism,  to  a  greater  or  less  degree,  ex- 
ists in  every  case  of  fracture.  It  is  most  evidently  present  in 
those  cases  associated  wdth  great  laceration  of  tissue  and  in  open 
fractures.  The  soft  fat  of  the  medullary  tissue  is  the  source  of 
the  fat-drops  that,  getting  into  the  venous  circulation,  are  carried 


334 


I-RACTIKUS    OF    THE    FEMUR 


dire-ctlv  to  the  pulmonary  capillaries,  where  they  lodge  unless  the 
blood  pressure  is  suiTicient  to  force  them  out  of  the  lung  capillaries 
on  into  the  systemic  circulation.  They  then  lodge  in  the  brain, 
kidneys,  or  other  organs.  The  danger  in  fat  embolism  is  that  the 
patient  mav  die  from  asphyxiation,  due  to  the  imperfect  oxygena- 
tion of  the  blood  because  of  the  rapid  occlusion  of  the  pulmonary 
capillaries  with  fat  globules. 

vSymptoms. — Svmptoms  develop  within  twenty-four  to  seventy- 
two  hours  after  the  accident.  In  fatal  cases  facial  pallor  and  dis- 
tress are  followed  by  cyanosis.  The  patient  is  first  excitable,  rest- 
less, then  somnolent  and  comatose.      Death  occurs  from  asphyxia. 

The  temperature  is  usually  not  elevated.  Respiration  is  rapid. 
Hemoptvsis  mav  exist,  associated  with  pulmonary  edema.  Fat 
globules  will  be  found  in  the  urine  usually  upon  the  second  and 
fourth  days  after  the  accident,  for  they  are  eliminated  by  the 
kidney. 

A  difficultv  in  breathing,  cyanosis,  and  fat  found  in  the  urine 
may  be  the  only  evidences  of  a  fat  embolism.  The  prognosis  is, 
of  course,  dependent  upon  the  extent  of  the  embolism  and  the 
strength  of  the  heart.  The  occurrence  of  fat  embolism  is  not  un- 
common.    Death  from  fat  embolism  is  rare. 

Treatment. — Stimulation  of  the  heart  for  its  extra  work  is  in- 
dicated. ImmobiHzation  of  the  fractured  part  to  prevent  more 
fat  from  getting  into  the  circulation  and  the  administration  of 
oxvgen  to  relieve  asphyxia  are  important  in  the  treatment. 


CHAPTER  XIII 

FRACTURES  OF  THE  PATELLA 

Anatomy. — A  knowledge  of  the  anatomical  relations  of  the 
patella  is  necessary  to  a  perfect  understanding  of  the  fractures  to 
which  it  is  liable  (see  Figs.  435-437).  Attached  to  the  patella 
upon  its  upper  border  is  the  tendon  of  the  quadriceps  extensor 
muscle.  Upon  each  side  of  the  bone  are  attached  the  vastus  in- 
ternus  and  vastus  externus  respectively.  Below  the  insertions  of 
the  vasti  is'  a  portion  of  the  low  attachment  of  the  fascia  lata  of 


F'g-  435.— Anterior  view  of  normal  patella. 

the  thigh.  At  the  lower  border  of  the  patella  is  the  patellar  ten- 
don. This  tendon  is  inserted  into  the  tubercle  of  the  tibia,  and 
it  is  separated  from  the  head  of  the  tibia  by  a  bursa  and  a  pad  of 
fat  tissue.  The  tendon  of  the  quadriceps,  the  insertions  of  the 
vasti  muscles,  and  the  patellar  tendon  are  all  continuous  with  the 
strong  fascia  lata  surrounding  the  thigh.  The  fascia  lata  is  at- 
tached below  to  the  condyles  of  the  femur,  the  sides  of  the  patella, 
the  tuberosities  of  the  tibia,  the  head  of  the  fibula,  and  to  the  deep 
fascia  of  the  leg  in  the  popliteal  space.     The  patella  is  seen,  there- 

335 


336 


FRACTURES    OF    THI-;    PATHIJ.A 


fore,  to  lie  in  a  strong  fibrous  sheath  that  encircles  the  knee  and 
is  attached  to  various  bony  prominences  (see  Figs.  438,  439). 
The  synovial  membrane  of  the  knee-joint  lies  directly  beneath 
and  attached  to  the  posterior  surface  of  the  patella.  Laterally 
and  posteriorly  the  synovial  membrane  lies  next  to  the  encircling 
fascia  of  the  joint.  The  deep  bursa  of  the  femur  lies  in  front  of 
the  lower  end  of  the  femur  beneath  the  quadriceps  muscles,  and 
often  communicates  with  the  knee-joint.  The  tubercle  of  the 
tibia  is  on  a  level  with  the  head  of  the  fibula.  The  outline  and 
anterior  surface  of  the  patella  can  be  palpated  throughout.  AMien 
the  leg  is  completely  extended  and  is  at  rest,  the  patella  can  be 


Fig.  436. — Posterior  view  of  normal  patella, 
showing  the  two  articular  surfaces  for  the  con- 
dyles of  the  femur.  Note  the  lovi-er  tip  of 
patella  is  e.\tra-articular. 


Fig.  437. — Lateral  view  of 
normal  patella.  Note  lower 
portion,  extra-articular. 


removed  from  side  to  side.  The  numerous  longitudinal  striae  on 
the  anterior  surface  of  the  patella  can  be  detected.  In  these  the 
tendinous  bundles  of  insertion  of  the  rectus  are  embedded.  It  is 
these  fibers  that  fold  in  over  the  broken  patella  and  prevent  the 
approximation  of  the  fragments.  The  ligament  of  the  patella  is 
parallel  with  the  axis  of  the  leg. 

Fracture  of  the  patella  occurs  through  either  muscular  contrac- 
tion (see  Fig.  441)  and  strain  or  through  direct  violence.  The 
form  of  the  fracture  is  not  altogether  dependent  upon  the  causa- 
tive force.  The  fracture  will  be  either  transverse  and  clean  cut  or 
comminuted  and  irregular.     The  knee-joint  is  generally  opened: 


SYMPTOMS 


337 


i.  e.,  the  synovial  membrane  is  generally  torn.  The  synovial 
membrane  is  reflected  from  the  posterior  surface  of  the  patella 
some  distance  from  the  most  inferior  tip  of  the  bone.  It  is  pos- 
sible, therefore,  for  a  fracture  to  occur  at  the  lower  portion  of  the 


Patella. 


Synovial  membrane, 
cavity  of  joint. 


Femur. 


Fig.  438.— Horizontal  frozen   section  of  the  knee-joint,  showing  lateral   extent  of   synovial 
membrane  (Professor  Dwight's  specimen). 


Fig.  439. — Ligamentous  preparation  of  the  knee,  the  patellar  tendon  cut  just  below  the 
patella,  dissected  out,  and  reflected  downward.  Shows  the  lateral  expansions  of  the  quadri- 
ceps tendon  extending  to  the  tibia  (from  dissection  by  Professor  Dwight). 


bone  for  some  considerable  distance  from  the  lower  edge  without 
opening  the  knee-joint  (see  Fig.  442). 

Symptoms. — There  are  pain  in  the  knee  and  immediate  disabil- 
ity, varying  from  partial  to  complete  loss  of  power  in  extension 


Fig.  440. — Skiagraph  of  normal  right  knee-joint  in  an  adult. 


338 


A 


Fig.  441. — A,  Nearly  median  section  of  the  knee-joint,  the  convex  surfaces  of  the  femur 
and  of  the  patella  in  contact.  B,  Diagrammatic  view,  showing  position  in  which  the  patella 
is  subjected  to  a  strain  on  contraction  of  the  quadriceps,  the  probable  mechanism  of  many 
patellar  fractures. 


Skin. 
Quadriceps  fascia. 


Skin. 


Ligamentum  patellae. 
Skin. 


S5'novial  membrane  with  under- 
lying fat  tissue. 


Joint  surface  of  patella. 


Point  of  reflection  of  synovia! 
membrane. 


Fig.  442. — Diagram  of   anteroposterior  section  of   patella  and  tendons,  showing  the  small 
extrasynovial  portion  of  posterior  surface  of  the  bone. 


339 


340  FRACTURES    OF    THE    PATELLA 

and  in  llcxion.  The  ])aliL'nl  niav  be  unable  to  rise  or,  if  he 
can  stand,  he  can  not  move  exee])t  backward,  and  then  onlv  by 
dragging  the  foot  of  the  injured  hmb  upon  the  ground.  The 
patient  is  often  unable  to  raise  the  heel  from  the  bed  when  Iving 
upon  the  back.  vSwelling  of  the  knee,  which  at  first  is  slight, 
after  three  or  four  hours  may  become  very  great  (see  Fig.  44,^). 
The  swelling  is  due  to  the  accumulation  of  blood  and  synovial 
fluid  in  the  knee-joint.  A  traumatic  synovitis  exists.  The  im- 
mediate swelling  of  the  knee  mav  become  great  enough  to  demand 
an  incision  to  relieve  the  tension  upon  the  skin,  to  prevent  slough- 
ing of  the  skin  above  the  broken  patella.  Immediately  after  the 
accident  crepitus  may  be  elicited  by  pressing  the  two  fragments 


Fig.  443. — Case:  Right  knee  normal  ;  left  knee,  fracture  of  patella.     Two  days  after  accident. 
Observe  swelling  of  whole  knee.    Joint  filled  with  fluid. 

together.  When  the  knee-joint  is  distended  by  fluid,  it  is  often 
impossible  even  to  detect  the  fragments  of  the  patella,  but  as  the 
fluid  subsides  and  the  sulcus  between  the  bones  is  felt,  crepitus 
can  again  be  detected.  The  degree  of  the  separation  of  the  frag- 
ments is  dependent  upon  the  amount  of  distention  of  the  joint 
and  upon  the  extent  of  the  tearing  of  the  lateral  aponeurosis 
(fascia  lata)  of  the  knee,  permitting  muscular  contraction  and 
retraction.  If  the  causative  violence  is  associated  with  a  wound 
of  the  soft  parts,  there  will  be  evident  a  contusion  or  an  abrasion 
of  the  skin  or  a  lacerated  wound  opening  the  knee-joint,  making 
the  fracture  an  open  one. 

Treatment. — The  indications  to  be  met  are  the  limitation  and 
removal   of   the   effusion,   the    reduction    of   the    fragments,    the 


Fig.  444.— Fracture  of  patella;  fibrous 
union.  Broadening  of  lower  fragment 
(Warren  Museum,  specimen  3652}. 


Fig.  446. — Fracture  of  patella  ;  bony 
union ;  some  elongation  of  bone  as  a 
whole.  View  from  side  f  Warren  Museum, 
specimen  6707). 


Fig.  445. — Fracture  of  patella  ;  union 
with  long  fibrous  band  ;  separation  of  frag- 
ments 3%  inches  (Warren  Museum,  speci- 
men 5253). 


Fig.  447. — Ham-splint  without  strap, 
showing  proper  length  and  relation  to 
thigh  and  leg  posteriorly. 


341 


34- 


FRACTURES    OF    THE    PATELLA 


maintenance  of  the  reduction  until  union  is  satisfactory,  and  the 
restoration  of  the  functions  of  the  joint  to  their  normal  condition. 
77/('  Li))ut(itii'ii  iDuI  Removal  o/  the  Efiitsioii.  —  If  the  fracture  is 
seen  before  there  is  great  swelling,  limitation  of  the  swelling  may 
be  effected  by  immobilization  of  the  knee  and  the  accurate  appli- 
cation of  an  elastic  rubber  bandage.  If  the  bandage  is  not  at 
hand,  sponge  compresses  may  be  used — viz.,  two  slightly  moist- 


i 

r 

/ 

m 

.^8IV^ 

^ 

l|l|^^^      ^^^^^H 

Fig;.  44S. — Inipioper  method  of  applying  a  ham-splint.     The  knee-joint  is  not   immobilized 
Flexion  is  possible.     Straps  i  and  2  are  insufficient. 


Fig.  449. — Proper  method  of   applying  a  ham-splint.     The  third  adhesive-plaster  strap  (3) 
prevents  flexion  of  the  knee. 


ened  bath  or  carriage  sponges  are  allowed  to  dry  under  pressure 
sufiEicient  to  flatten  them.  These  are  placed  upon  each  side  of  the 
knee  and  over  it,  and  are  held  by  a  few  turns  of  a  roller  bandage. 
Cool  water  is  then  poured  over  the  whole.  As  the  sponges  absorb 
the  water  they  enlarge,  causing  equable  and  firm  pressure  on  the 
knee,  thus  very  materially  hindering  the  accumulation  of  fluid 
and  favoring  its  absorption.     These  wet  sponge  compresses  should 


EXPECTANT    TREATMENT 


343 


be  left  in  position  for  from  twelve  to  twenty-four  hours,  and  then 
a  fresh  set  used. 

Massage  skilfully  applied  to  the  whole  limb,  irrespective  of  the 
method  of  treatment  eventually  instituted,  will  not  only  assist  in 


Fig.  450. — Expectant  method  of  treating  fracture  of  the  patella.  Leg  extended  on  pos- 
terior wire  splint.  Fragments  held  by  two  straps.  Fluid  has  left  the  joint.  ^,  Side  splints  ; 
B^  coaptation  splints  reflected. 


Fig.  451. — Expectant  method  of  treating  fracture  of  the  patella.     Same  as  figure  450,  with  the 
addition  of  coaptation  splints  to  the  thigh,  padding,  and  straps. 


the  absorption  of  the  fluid,  but  will  preserve  intact  the  muscles  of 
the  limb.  Massage  to  be  effective  should  be  applied  at  least  twice 
daily,  and  from  fifteen  minutes  to  half  an  hour  at  a  time.  Slight 
pain  will  be  felt,  but  after  a  time  massage  will  be  painless  and  give 
great  comfort. 


344 


FRACTIKHS    OF    THE    PATKI.I.A 


The  Reductiou  oj  the  I-'roQDioiis. — Xo  altenipt  shoukl  be  made 
to  reduce  the  fragments  uiilil  nearly  all  the  lluid  is  removed  from 
the  knee-joint.  Reduction  is  accomj)lished  bv  immobilization 
of  the  knee-joint,  by  fixation  of  the  lower  fragment,  and  bv  trac- 
tion upon  and  fixation  of  the  upper  fragment.  The  leg  should  be 
extended  completclv  and  the  knee  immobilized  either  upon  ham- 
splint  (see  Figs.  447,  44S,  449)  or  upon  a  Cabot  posterior  wire 
splint.  The  ham-splint  is  preferably  made  from  a  plaster-of- 
Paris  bandage.  The  lower  fragment  is  held  fixed  bv  a  strap,  pref- 
erablv  of    adhesive  plaster,  placed  obliciuelv  about  the  leg    and 


Fig.  452. — Expectant  method  of  treating  fracture  of  the  patella.  Same  as  figure  451, 
with  the  addition  of  two  lateral  splints,  padding,  and  straps.  A  posterior  wooden  splint, 
seen  better  in  figure  451,  and  elevation  of  the  limb. 


splint,  and  fastened  to  the  splint  above  the  fragment  (see  Figs. 
450,  451,  452,  453).  The  upper  fragment  is  drawn  down  first  by 
elevation  of  the  leg  upon  an  inclined  plane,  which  relaxes  the 
quadriceps  extensor  muscle,  then  by  traction  obtained  by  a  strap 
passed  obliquely  above  the  upper  fragment  and  fastened  to  the 
splint  below^  the  fragment.  The  upper  strap  will  need  repeated 
adjustment  as  the  plaster  slips  and  as  the  fluid  disappears  from 
the  joint.  To  facilitate  traction  by  this  upper  strap,  the  quad- 
riceps muscle  should  be  held  firmly  by  coaptation  splints  and 
straps  encircling  the  posterior  splint.  The  quadriceps  can  not 
then  actively  pull  upon  the  upper  fragment.     The  tendency  of 


EXPECTANT    TREATMENT 


345 


these  two  straps  thus  apphed  will  be  to  tilt  the  broken  surfaces 
of  the  two  fragments  upward  and  apart,  particularly  if  there  is 
fluid  in  the  joint.  It  is  important,  therefore,  to  place  a  third 
strap  over  the  two  broken  edges  of  the  fragments,  in  order  to  hold 
them  down  to  their  proper  level  and  to  assist  in  bringing  them  into 


Fig.  453. — Expectant  method 
of  treating  fracture  of  the  patella. 
Anterior  view  of  apparatus  com- 
plete. The  padding  of  the  side 
splints  is  shown. 


Fig.  454. — Extent  of  flannel  bai*dage  to  knee, 
applied  after  all  immobilizing  apparatus  is  re- 
moved.    The  bandage  is  started  at  I. 


apposition.  The  coaptation  splints  should  be  removed  at  every 
massage  treatment,  the  upper  fragment  being  steadied  by  an 
assistant.  The  straps  about  the  patella  need  not  be  removed 
during  the  massage.  They  will  be  of  no  inconvenience.  As  soon 
as  the  effusion  has  left  the  joint,  all  will  have  been  gained  in  the 
reduction  of  the  fracture  that  can  be  gained  bv  this  method. 


346  FRACTURES    OF    THK    PATELLA 

Aspiration  of  the  knee-joint  by  means  of  a  narrow  knife  incision 
or  by  means  of  a  karge-sized  trocar  is,  if  done  under  striclh-  anti- 
septic precautions,  and  forty-eight  hours  after  the  fracture,  often 
satisfactory  in  immediately  removing  the  bulk  of  the  effusion;  if 
firm  compression  is  then  made,  it  effectually  prevents  the  reac- 
cunuilation  of  fluid. 

Mai}itc)ia>icc  of  Reduction  until  Union  is  Satisjactorv. — At  the 
end  of  about  four  or  six  weeks  from  the  injurv  union  will  be  found. 
All  lluid  will  luu'e  left  the  joint.  The  retentive  straps  and  coapta- 
tion splints  may  now  be  removed.  The  leg  should  be  immobilized 
by  means  of  a  plaster-of- Paris  splint  extending  from  just  below  the 


I"  i.'^-  IS^- — * '1<1  Irarture  <A  patella  ;  great  separation  of  fragments.  Ci)ndyles  of  the  femur 
are  prominent  in  between  fragments.  Leg  was  useful,  but  weak.  ^,  The  lower  fragment ; 
B,  the  condyles  of  the  femur  ;   C,  the  upper  fragment. 


sw^ell  of  the  calf  to  the  groin.  This  splint  is  split  on  the  side  or 
posteriorly  and  arranged  as  a  removable  dressing.  Proper  bath- 
ing is  facilitated.     This  enables  the  masseur  to  work. 

The  removable  splint  is  made  thus :  A  light  weight  plaster-of- 
Paris  roller  bandage  is  applied  to  the  properly  protected  leg  from 
above  the  ankle  to  the  groin.  It  is  split  in  the  median  line  its 
whole  length  before  the  plaster  has  quite  hardened.  It  is  sprung 
off  the  leg.  After  it  is  hard  a  narrow  strip  of  leather,  upon  which 
are  fastened  lacing  hooks,  is  stitched  to  each  cut  edge.  This 
splint  may  now  be  sprung  on  the  limb  and  laced  snugly  in  posi- 
tion.    A  leather  splint  may  be  similarly  made  from  a  plaster  cast 


EXPECTANT   TREATMENT 


347 


and  mold  of  the  limb.  As  soon  as  union  is  firm,  the  patient 
should  be  up  and  about  with  the  light  removable  fixation  splint 
applied,  walking  with  the  aid  of  crutches. 

Fixation  (prevention  of  flexion  and  extension)  on  walking  is  to 
be  maintained  for  at  least  six  months  after  the  injury.  Protect- 
ing the  knee  thus  when  walking  for  this  period  of  six  months  does 
not  preclude  active  movements  of  the  knee  when  not  bearing 


i 

1                                            .  ^ 

] 

■" 

Fis 


456. — Case :  Fracture  of  the  patellae.    Moderate  separation   of  the   fragments  of  each 
knee-joint.     Useful  legs. 


weight  upon  the  limb.  At  the  end  of  that  time  the  patient  may 
be  allowed  to  go  about  with  a  cane  and  a  snugly  fitting  roller  ban- 
dage (see  Fig.  454).  This  bandage  should  be  made  of  medium 
weight  flannel,  cut  straight  with  the  weave  and  not  on  the  bias. 
The  bandage  should  be  applied  from  the  middle  of  the  calf  of  the 
leg  to  the  middle  of  the  thigh  when  the  leg  is  completely  extended. 
As  the  patient  becomes  confident  of  his  strength,  the  cane  need  not 
be  carried.     Sudden  movements  are  to  be  avoided.     At  the  end 


348 


FRACTURES    OF    THE    PATELLA 


of  eight  or  ten  iiionllis,  var\-ing  with  the  indivichial  case,  all  sup- 
port may  be  omitted  from  the  knee. 

The  Restoration  oj  the  Function  of  the  Joint. — From  the  day  of 
the  injury  daily  massage  to  the  whole  limb  is  important.  It  main- 
tains the  muscles  in  good  tone.  It  prevents  adhesion  of  the  frag- 
ments to  the  tissues  about  the  condyles  of  the  femur,  a  not  un- 
common cause  of  ankylosis  of  the  joint.  It  facilitates  the  absorp- 
tion of  the  effusion  of  blood  and  synovial  lluid.  After  the  fourth 
week  daily  passive  motion  is  to  be  instituted :  at  first  very  slight 


F'g-  457- — Fracture  of  upper  third  of  patella,  showing  separation   of  fragments.     Tilting  of 
the  upper  fragment  through  rotation  upon  its  transverse  axis  (X-ray  tracing). 


indeed,  barely  two  or  three  degrees.  If  the  relative  position  of  the 
fragments  is  not  altered  perceptiblv  bv  this  passive  motion  and 
lasting  pain  is  absent,  it  may  be  persisted  in  with  regularly  increas- 
ing amounts.  At  the  expiration  of  eight  or  ten  weeks  active  mo- 
tion at  the  knee-joint  may  cautiously  be  allowed.  The  appear- 
ance of  persistent  and  increasing  tenderness,  sensitiveness,  or  pain, 
and  increasing  separation  of  the  fragments  are  the  indications  to 
diminish  or  cease  passive  and  active  motions. 

Summary  of  the  Treatment  of  Fracture  of  the  Patella  by  the 
Expectant  or  Nonoperative  Method. — During  four  weeks  fixation 


OPEN  FRACTURE  OF  THE  PATEEEA 


349 


of  the  knee,  elastic  compression,  douching,  massage,  the  thigh 
flexed  shghtly  on  pelvis,  the  leg  extended,  retentive  straps,  coap- 
tation splints,  are  the  measures  employed.  At  the  fourth  or  sixth 
week,  remove  all  apparatus,  apply  removable  splint,  allow  walking 
with  crutches,  and  use  daily  passive  motion.  At  the  eighth  week, 
discard  crutches,  use  cane,  and  permit  limited  daily  active  motion. 
At  the  sixth  month,  discard  splint,  apply  flannel  bandages,  and 


Fig.  458. — Fracture  of  the  patella  in 
the  lower  third,  showing  tilting  of  lower 
fragment  through  rotation  on  its  trans- 
verse axis  (X-ray  tracing). 


Fig.  459. — Fracture  of  lower  edge  of 
patella.  Little  separation  of  fragments. 
Indirect  violence  (X-ray  tracing). 


discard  cane.     At  the  eighth  to  the  tenth  month,  remove  all  sup- 
port. 

Open  Fracture  of  the  Patella. — This  is  a  very  serious  injury, 
because  one  of  the  largest  synovial  cavities  of  the  bodv  is  exposed 
to  infection.  It  is  safest  and  wisest  to  lay  open  the  knee-joint, 
to  thoroughly  irrigate  it  with  a  solution  of  corrosive  sublimate 
(i :  10,000),  and  then  with  a  sterilized  normal  salt  solution.  All 
blood-clots  should  be  carefully  wiped  away.  All  loosely  attached 
fragments    of    bone    should    be    removed.     Particular    attention 


350 


FRACTURES  OF  TIIH  PATELLA 


should  be  paid  to  the  posterior  parts  of  the  joint,  behind  the  con- 
dyles of  the  femur.  It  will  he  found  convenient  in  cleaning  these 
parts  first  to  Hush  the  joint  with  sterile  salt  solution  and  to  ilex 
and  to  extend  the  knee.  All  parts  of  the  joint  posteriorly  are 
thus  likelv  to  be  thoroughly  Hushed.  The  fragments  should  be 
approximated  and  sutured  by  some  absorbable  suture.  The  skin- 
wound  should  be  closed.     The  knee-joint  should  be  immobilized 


Fig.  460.— Double  fracture  of  patella  without  great 
separation  of  fragments  (X-ray  tracing). 


Fig.  461. — Transverse  fracture  of 
patella,  showing  straps  in  position  to 
hold  fragments  (X-ray  tracing). 


in  a  posterior  wire  splint  and  side  splints  or  in  a  plaster-of- Paris 
splint. 

Prognosis. — Ordinarily,  an  individual  should  not  follow  his 
occupation  for  about  six  weeks  to  two  months  after  a  fracture  of 
the  patella — i.  e.,  unless  the  occupation  can  be  conducted  with 
a  leg  held  stiffly  at  the  knee.  The  functional  usefulness  of  the 
limb  and  not  anatomical  considerations  should  be  the  chief  crite- 
rion in  determining  the  result  following  fracture  of  the  patella. 
If  a  man  can  earn  his  living  as  before  the  accident  without  local 


PROGNOSIS    AFTER    EXPECTANT   TREATMENT  35 1 

discomfort  or  hindrance,  he  possesses  a  useful  Hmb.  It  makes 
Httle  difference  if  there  is  a  shght  separation  of  the  fragments  or  a 
suggestion  of  a  Hmp  or  sHght  atrophy  of  the  thigh  and  calf  muscles ; 
these  conditions  are  all  to  be  accepted  as  part  of  the  irreparable 
damage,  and  are  trivial.  In  nonoperative  cases  the  union  is 
usually  fibrous  although  it  may  be  bony.  The  interval  between 
the  fragments  may  amount  to  five  or  six  inches.  The  approxi- 
mation of  the  fragments  of  the  patella  is  not  evidence  of  strength, 
for  the  fibrous  bond  of  union  may  be  much  narrower  than  the 
fractured  surface  and  very  thin,  and  thus  easily  ruptured.     The 


\ 
\ 
\ 
\ 
\ 
\ 
\ 


I  \ 

Fig.  462.— Comminuted  stellate  fracture  of  patella  through  direct  violence  (X-ray  tracing). 

usefulness  of  the  limb  after  fracture  of  the  patella  is  not  dependent 
upon  any  one  factor,  either  the  kind  of  union  or  the  extent  of  the 
separation  of  the  fragments  of  bone.  There  are  usually  no  adhe- 
sions of  the  upper  fragment  to  the  femur;  but  injury  to  the  bursa 
under  the  quadriceps  may  cause  troublesome  adhesions  upon  the 
anterior  surface  of  the  thigh.  Full  flexion  is  a  common  result, 
but  there  is  often  limitation  of  active  extension.  There  almost 
always  remains  a  little  joint  stiffness,  despite  both  massage  and 
active  and  passive  motion;  this,  unless  due  to  fibrous  adhesions, 
disappears  gradually.  The  majority  of  cases  of  fracture  of  the 
patella  under  careful  nonoperative  treatment  will  secure  a  useful 


352 


FRACTURES    OF   THE    PATELLA 


limb.  A  patella  once  fractured  and  having  united  by  fibrous  or 
b()n\-  union  nv.w  1)C  broken  through  the  callus  (^f  the  healed  frac- 
ture or  in  an  entireh'  dilTerent  fracture  from  the  first  break. 

Results  after  Fracture  of  the  Patella. — In  a  series  of  forty- 
seven  cases  of  fracture  of  the  patella  treated  at  the  Massachusetts 
General  Hospital,  occurring  between  the  ages  of  eleven  and  sixty- 
five  years,  four  were  over  fifty  years,  thirteen  were  under  twenty- 


Fig.  463. — Old  fracture  of  patella.  Much 
separation  of  fragments.  Small  nodules  of 
bone  seen  in  the  band  of  union  (X-ray  tracing). 


Fig.  464. — Old  fracture  of  patella. 
Wide  separation  of  fragments.  Dimp- 
ling of  skin.  A  useful  but  not  a  strong 
leg  (Massachusetts  General  Hospital, 
847.     X-ray  tracing). 


five  years,  twenty-nine  were  between  twenty-five  and  forty-five 
years,  one  was  forty-seven  years  old ;  practically,  a  young  adult 
series.  Of  this  series  of  forty-seven  cases  ten  were  treated  by 
operation  and  the  remainder  by  the  expectant  method.  These 
cases  are  not  mentioned  in  this  connection  to  compare  methods 
of  treatment,  but  to  determine  the  condition  of  the  knee  a  long 
time  after  the  injury.  As  a  matter  of  fact,  there  appeared  no 
greater  freedom  from  the  symptoms  complained  of  among  the 


RESULTS  AFTER  FRACTURE  OF  THE  PATELLA 


353 


cases  operated  on  than  among  those  unoperated.  The  results,  as 
carefully  recorded  in  these  forty-seven  cases,  suggest  some  of  the 
difficulties  that  patients  experience  after  fracture  of  the  patella. 
The  detailed  reports  of  these  cases,  from  one  and  one-half  to  ten 
and  one-half  years  after  treatment  ceased,  show  that  about  twenty 
have  as  good  a  leg  as  before  the  accident.     The  remaining  twenty- 


Fig.  465.— Fracture  of  the  patella,  showing  fascia  lying  over  broken  surfaces.     Smaller  figure 
shows  one  portion  of  fascia  picked  up  in  forceps  (Aitken). 


seven  cases  complain  of  limitation  of  motion  at  the  knee-joint,  that 
the  knee  creaks  in  walking,  that  it  feels  stiff,  aches,  and  bums  at 
times.  The  leg  is  said  to  be  weak,  and  is  troublesome  in  going  up 
and  down  stairs — stepping  up  is  especially  difficult;  kneeling  is 
painful ;  stepping  upon  irregular  surfaces  is  painful ;  running  with 
the  same  freedom  as  before  the  accident  is  impossible;  the  knee 
2.3 


354 


FKACTrRHS    OF    TIlIv    rATEl.LA 


often  gives  \va\-  in  walkinj;  and  causes  a  fall;  the  patient  can  not 
juni]:)  as  before  tlie  accident,  and  walks  with  a  slight  limp.  Pain 
is  present  in  or  about  the  knee  in  damp  weather  and  after  unusual 
exertion. 

Operative  Interference  in  Recent  Closed  Fractures  of  the 
Patella. — In  deciding  whether  a  given  case  should  be  treated  by 
operation  or  not  the  following  considerations  should  be  carefully 
weighed :  A  closed  fracture  of  the  patella  does  not  in  itself  endan- 
ger life.      It  may  be  treated  by  the  conservative  method  without 


Fig.  466.— Fracture  of  patella;  fragment  approximated  and  sutured  with  silver  wire.     Wire 
seen  in  silii  (X-ray  tracing.     C.  B.  Porter). 


added  risk.  If  properly  treated,  the  result  will  often  be  satis- 
factory as  far  as  the  functional  usefulness  of  the  knee  is  con- 
cerned. The  operative  method  consumes  less  time  in  convales- 
cence and  an  excellent  result  is  achieved,  but  operation  exposes 
to  the  danger  of  sepsis.  If  sepsis  results,  the  following  conditions 
are  imminent :  A  stiff  knee,  amputation  of  the  thigh,  and  possibly 
death  from  septic  infection,  ^^'hether  operation  shall  be  done  or 
not,  therefore,  depends  upon  the  degree  of  safety  with  which  it 
can  be  performed.  It  is  the  surest  method  of  securing  perfect 
apposition  and  bony  union.      It   should  be  undertaken  only  by 


OPERATIVE    TREATMENT 


35.5 


surgeons  of  exceptional  judgment  and  great  skill,  who  have  at 
command  skilled  assistants,  and  who  can  work  under  the  most 
rigid  aseptic  conditions.  The  acute  symptoms  should  be  allowed 
to  subside  before  operation.  The  tissues  require  time  to  recover 
from  the  acute  trauma.  The  operative  treatment  should  be 
confined  to  healthy  individuals  under  sixty  years  of  age;  to 
fractures  with  a  distinct  separation  of  the  bony  fragments 
and  extensive  lateral  fascial  tears  (the  fascial  tears  may  be 
recognized  by  joint  distention  and  localized   bulging) ;  to  cases 


Fig.  467. — Case  :  Freshly  fractured  right  patella  sutured  with  chromicized  catgut.     Result 
after  eight  weeks.     Note  flexion  of  leg  to  a  right  angle  ;  line  of  incision  (Warren). 


presenting  great  joint  distention  that  does  not  disappear  quickly. 
It  should  be  seriously  considered  if  the  individual's  occupation  is 
arduous  and  necessitates  much  standing  or  walking.  The  patient 
should  be  informed  as  to  the  probable  outcome  bv  the  two  methods 
of  treatment.  The  danger  to  life  and  limb  should  be  fairly  stated. 
It  should  be  remembered  that  the  power  of  extension  of  the  leg  is 
not  materially  limited  by  a  transverse  fracture  of  the  patella  in 
which  the  tearing  of  the  lateral  fascia  is  absent.  Only  in  direct 
proportion  to  the  extent  of  the  lateral  fascial  tear  is  there  limita- 


356  FRACTl'RKS  OF  THH  PATELLA 

tion  of  the  power  of  extending  the  leg  upon  the  thigh.  In  open 
fractures,  in  refracture,  and  in  cases  of  impaired  function  from 
long  fibrous  union  or  from  adhesions  of  the  patella  or  from  badly 
united  patelke  mechanical!)-  impeding  the  mo\-emcnts  of  the  joint, 
operation  is  always  indicated.  The  working-man  who  wants  to 
get  to  work  should,  under  the  conditions  previously  stated,  have 
his  patella  sutured,  for  he  will  go  to  work  quicker  and  have  a 
better  knee-joint  than  by  any  other  method  of  treatment. 

Method  of  Operation. — The  joint  and  the  fractured  bones  are  to 
be  thoroughly  exposed  by  a  transverse  or  longitudinal  incision. 
All  clots  should  be  thoroughly  washed  or  sponged  out.  Any 
loose  small  fragments  of  bone  should  be  removed.  In  almost  all 
cases  a  rather  dense  fascia  will  be  found  overlapping  the  broken 
surfaces  of  the  two  fragments  (especially  is  this  seen  in  a  trans- 
verse fracture).  These  bits  of  overlapping  tissue  or  curtains  of 
tissue  should  be  retracted  and  removed  or  utilized  in  suturing  the 
fragments  (see  Fig.  465).  Whether  silver  wire  is  employed  to 
suture  the  bone  directly  or  whether  an  absorbable  material  is 
used  to  suture  the  soft  parts  seems  of  little  consequence  as  long  as 
all  fascial  tears  are  sutured  and  the  bony  fragments  are  approxi- 
mated (see  Fig.  466).  The  weight  of  opinion  to-day  is  in  favor  of 
absorbable  sutures.  Closure  of  the  joint  without  drainage  and 
immobilization  in  the  extended  position  followed  by  the  treatment 
already  mentioned  are  indicated  (see  Fig.  467). 

The  Restoration  of  the  Function  of  the  Joint  Following  the  Opera- 
tive Treatment. — After  suture  of  the  patella,  massage  and  gentle 
passive  motion  should  be  begun  at  the  end  of  two  weeks.  At  the 
end  of  three  weeks  the  patient  may  go  about  with  the  knee  pro- 
tected by  a  light  stiff  dressing.  After  about  six  weeks  to  two 
months  a  fiannel  bandage  and  a  cane  will  be  all  the  protection 
needed  to  the  knee.  At  the  end  of  three  months  the  knee  should 
be  functionally  perfect. 


CHAPTER  XIV 

FRACTURES  OF  THE  LEG 

Anatomy. — The  following  structures  may  be   palpated:  The 
internal  and  external  tuberosities  of  the  tibia,  the  whole  of  the 


Fig.  468.— Middle  of  the  patella,  tuber- 
cle of  the  tibia,  and  midpoint  between  the 
malleoli  all  lie  in  the  same  straight  line  as 
the  leg  rests  naturally. 


469. — Fracture  of  the  tibia,  low  down 
(Warren  Museum  specimen). 


external  tuberosity  being  subcutaneous;  the  broad  anterior  and 
inner  surface  of  the  tibia,  which  forms  the  shin,  downward  to  the 

357 


358 


FRACTIKUS    OF    THE    LEG 


iniLTual  malleolus;  the  sharp  crest  of  the  tibia  throughout  its 
whole  length;  the  head  of  the  hbula,  an  inch  below  the  top  of  the 
tibia ;  a  little  of  the  shaft  of  the  hbula  below  the  head  and  the  at- 
tachment of  the  biceps  tendon ;  the  lower  third  of  the  fibula  which 
is  subcutaneous.  The  tubercle  of  the  tibia  is  distinctly  felt  on  the 
anterior  surface  of  the  upper  end  of  the  tibia.  It  is  one  inch  from 
the  articular  surface,   and  marks  the  lowest  limit  of  the  upper 


Fig.  470. — Fracture  of  both  hones  of 
the  leg,  high  up  (Warren  Museum  speci- 
men). 


Fig.  471. — Old  fracture  of  tibia.  Union 
in  malposition  ;  section  of  bone  showing 
relative  position  of  fragment  at  seat  of 
union  (Warren  Museum  specimen). 


epiphysis  of  the  tibia.  Into  it  is  inserted  the  patellar  tendon. 
The  shaft  of  the  tibia  arches  slightly  forward.  The  shaft  of  the 
fibula  arches  slightly  backward.  The  broad  inner  malleolus  is 
higher  than  the  outer  malleolus,  and  more  to  the  front  of  the  leg. 
The  outer  malleolus  is  narrow^  The  posterior  edges  of  the  two 
malleoli  are  in  about  the  same  plane.  The  anterior  edge  of  the 
external  malleolus  is  about  an  inch  behind  the  anterior  edge  of  the 
internal  malleolus.     The  narrowest  part  and  the  weakest  place  in 


ao 

0  rt  <" 

o    . 

1-"-  rt 

Oc« 

*j  rt 

.sa 

.a  "a 

rt  bj^'a 

«^  .i,  a— 

—  *j 

359 


s6o 


I-RACTrRES    OF    THE    LEO 


the  tibia  is  at  the  junction  of  the  lower  and  middle  thirds  of  the 
bone.  In  the  normal  leg  the  middle  of  the  patella,  the  tendon  of 
the  patella^  and  the  midpoint  of  the  ankle  are  in  the  same  straight 
line  (sec  Fig.  46S). 

General  Observations. — Fractures  of  the  tibia  and  fibula  may 


I^'g- 473- — Fracture  of  both  bones  of  the  leg-;  disjilacenienl  of  upper  fragments  downward 
and  inward  ;  union  (, Warren  Museum,  specimen  S303). 


occur  at  any  point,  depending  upon  the  seat  and  direction  of  the 
fracturing  force.  If  the  force  is  indirect,  the  fracture  of  the  two 
bones  will  be  at  different  levels.  If  the  fracture  is  high  up,  the 
knee-joint  may  be  involved  or  the  popliteal  vessels  and  peroneal 
nerve  may  be  implicated.      If  the  fracture  is  low  down,  the  ankle- 


GENERAL    f)I{SEKVATIONS  36 1 

joint  may  be  involved.  The  high  fracture  of  the  tibia  is  usually- 
transverse.  The  low  fracture  of  the  tibia  is  usually  oblique.  The 
common  seat  of  fracture  is  at  about  the  junction  of  the  middle 
and  lower  thirds  of  the  leg.  The  line  of  the  fracture  is  an  oblique 
one,  extending  from  above  and  behind  downward  and  forward 
through  the  tibia.  The  fibula  is  fractured  a  little  higher  than  the 
tibia.  If  the  force  is  considerable  and  the  sharpness  of  the  frag- 
ments great,  the  overlying  skin  may  be  lacerated,  an  open  or  in- 
fected fracture  resulting.  The  upper  and  lower  epiphyses  of  the 
tibia  may  be  separated;  these  are,  however,  rare  injuries.     The 


Fig.  474. — Method  of  measuring  the  length  of  the   tibia  from  the  internal  tuberosity  to  the 

internal  malleolus. 


tibia  and  fibula  may  be  fractured  separately.  In  such  cases  the 
unbroken  bone  serves  as  a  splint  for  the  fractured  one.  The  dis- 
placement in  these  latter  fractures  is  slight. 

It  is  not  very  unusual  in  young  athletic  adults  to  find  a  start- 
ing of  the  upper  epiphysis  of  the  tibia  as  illustrated  in  figure  472. 
Dr.  Robert  Osgood  has  demonstrated  recentlv  that  manv  ap- 
parently trivial  injuries — such  as  contraction  of  the  quadriceps 
extensor  muscle — to  the  region  of  the  tubercle  of  the  tibia  are 
in  reality  partial  separations,  with  or  without  some  displace- 
ment of  the  tongue-shaped  portion  of  the  upper  epiphvsis  of 
the  tibia,  or  actual  separation  of  an  independent  bony  center  for 


36: 


FRACTURES   OF    THE    LEG 


the  tubercle  of  the  tibia.  CHnically  slight  swelling  and  tenderness 
in  the  region  of  the  tibial  tubercle  and  pain  upon  extension  are 
the  chief  signs. . 

Dr.  Osgood  writes: 

"At  the  time  of  the  injury  there  is  felt  acute  pain  in  the  knee 
referred  to  below  the  patella.  There  is  often  slight  swelling,  either 
general  or  pretty  definitely  localized  over  the  region  of  the  tuber- 


Fig.  475. — Fracture  of  both  bones  of  the  left  leg.  Comparative  height  of  knees  to  show 
shortening  of  leg.  The  patient  is  sitting  with  knees  flexed  to  a  right  angle  (after  Van 
Lennep). 


cle.  There  is  distinct  tenderness  at  this  point.  The  ability  to 
use  the  leg  is  onlv  slightly  diminished,  and  the  acute  pain  is  soon 
replaced  by  a  feeling  of  weakness  on  strong  exertion.  Sharp  pain 
is  present  on  violent  extension  or  extreme  flexion  of  the  leg,  and 
the  patient  usually  consults  the  surgeon  because  of  this  pain,  the 
annoying  weakness,  and  the  continued  localized  swelling  or  tender- 
ness. 

"  The  condition  presents  no  complete  loss  of  function,   but  a 


METHOD    OF    liXAMINATlON  363 

severe  handicap  to  the  active,   athletic  Hfe  which  this  class  of 
patients  wish  to  lead." 

Complete  or  partial  immobilization  of  the  knee-joint  upon  the 
injured  side  for  a  longer  or  shorter  time  will  ordinarily  suffice  to 
effect  a  cure  of  the  difficulty- 
Examination  of  a  Fractured  Leg. — It  is  sometimes  extremely 
difficult  to  detect  a  fracture  of  the  leg.  It  is,  therefore,  important 
that  a  systematic  examination  should  be  made  immediately  after 
the  injury.  Deformity  will  ordinarily  be  apparent  upon  inspec- 
tion (see  Fig.  476).  Gentle  manipulation  will  suffice  to  satisfy  one 
of  the  existence  of  a  fracture,  particularly  if  both  bones  are  broken. 
An  open  fracture  will  be  evident  if  a  wound  exists  in  the  skin  near 


Patella. 


Fig.  476. — Case  :  Fresh  fracture  of  the  leg  (both  bones).  Characteristic  deformity.  Note 
normal  position  of  patella,  with  the  foot  lying  on  its  outer  side.  Prominence  of  upper  frag- 
ment. Compare  this  with  figure  380  of  a  fracture  of  the  thigh  in  which  the  patella  does  not 
look  upward. 


the  seat  of  fracture.  In  taking  hold  of  the  leg  for  examination  or 
for  moving  the  leg  it  should  not  be  grasped  lightly  by  a  few  fingers 
but  by  the  whole  hand  firmly,  as  one  grasps  an  ax  handle  in  chop- 
ping wood ;  not  as  one  lifts  a  lead-pencil  from  the  table.  The  leg 
should  be  so  raised  in  making  the  examination  that  there  is  abso- 
lutely no  risk  of  converting  the  closed  fracture  into  an  open  one. 
In  order  to  guard  against  this  the  assistant  should  grasp  the  foot 
at  the  ankle  and  make  gentle  but  strong  traction  in  the  long  axis  of 
the  leg  as  the  whole  leg  is  raised.  This  care  in  examination  will 
cause  the  patient  a  minimum  amount  of  pain.  Crepitus  is  not  the 
onlv  thing  that  is  to  be  sought  at  the  examination.  The  freedom 
of  any  abnormal  mobility  should  be  noticed,  as  well  as  the  direc- 
tion of  the  motion,  the  ease  with  which  reduction  is  possible,  and 


364 


FKACTrKI'S    OF    THU    LEG 


the  liahililv  to  recurrence  of  the  deformity.  If  there  is  any  doubt 
as  to  the  seat  or  extent  of  the  fracture,  the  examination  should  be 
made  with  the  assistance  of  an  anesthetic.     The  temporary  dress- 


Pig,  ly-. — Fracture  of  the  tibia,  oblique  and  high  up.     Ahiiost  no  displacement  (Massachusetts 
General  Hospital,  1235.     X-ray  tracing). 


Patella. 


Femur.  • 


Fibula. 


Fig.  478.— Fracture  of  the  external  tuberosity  of  the  tibia  (Massachusetts  General  Hospital. 
1242.     X-ray  tracing). 


ing  mav  be  appHed  at  this  time.  The  bones  should  be  palpated. 
\\'hile  an  assistant  steadies  the  knee-joint  the  surgeon,  grasping 
the  lower  part  of  the  leg,  attempts  motion  in  each  direction.     Sim- 


SYMPTOMS 


3^\5 


ply  raising  the  leg  and  attempting  motion  in  an  anteroposterior 
direction  is  not  sufficient;  a  fracture  of  the  tibia,  if  transverse, 
might  remain  completely  locked  except  upon  lateral  movement. 
The  tibia  should  be  measured  (see  Fig.  474)  from  the  knee-joint 
line,  at  the  upper  border  of  the  internal  tuberosity,  to  the  lower 
edge  of  the  internal  malleolus  to  determine  shortening.  vShorten- 
ing  of  the  leg  may  be  roughly  estimated  after  union  of  the  bones  by 
comparing  the  height  of  the  two  knees  while  the  soles  of  the  feet 
rest  upon  the  floor  (see  Fig.  475).     The  measurement  should  be 


Fig.  479.  —  Longitudinal  Assuring  of 
tibia  from  blasting  accident.  Front  view 
(X-ray  tracing). 


Fig.  4S0.  —  Longitudinal  fissuring  of 
tibia  from  blasting  accident.  Lateral  view. 
Same  as  figure  479  (X-ray  tracing). 


compared  with  that  of  the  uninjured  tibia.  It  is  often  difficult 
in  fractures  near  the  ankle  to  palpate  the  internal  malleolus,  on 
account  of  swelling.  Deep  pressure  with  the  thumb  will  detect  it. 
Inquiry  should  be  made  as  to  whether  either  tibia  has  ever  been 
fractured  previously.  The  pulse  should  be  felt  for  in  the  posterior 
tibial  and  dorsalis  pedis  arteries  to  be  sure  that  the  large  vessels 
of  the  leg  are  intact. 

Symptoms. — Ordinarily,  the  presence  of  pain,  deformity,  ab-j 
normal  mobility,  crepitus,  and  loss  of  use  of  the  leg  will  be  the  evi- 
dences of  fracture.     If  the  fracture  is  of  the  tibia  or  fibula  alone 


366 


FRACTl-RHS    OF    THE    LEG 


and  transverse  without  much  displacement,  locahzed  tenderness 
upon  pressure  and  swelHng  will  be  the  only  signs.  It  is  important 
to  remember  the, backward  bowing  of  llic  fibula  in  allemj^ting  to 
localize  by  palpation  the  tender  point  of  the  fracture  of  that 
bone. 

The  deformity  is  due  to  the  displacement  of  the  upper  fragment 
forward  and  of  the  lower  fragment  upward  and  backward.      If  the 


Fig.  4S1. — Oblique  fracture  of  the  tibia 
low  down,  and  oblique  fracture  of  the  fibula 
at  its  middle  (X-ray  tracing). 


Fig.  4S2. — Fracture  of  both  bones  of 
the  leg  at  the  middle;  slightly  sjiiral  of 
tibia  (Massachusetts  General  Hospital, 
1 134.     X-ray  tracing). 


fracture  is  oblique,  this  displacement  will  be  considerable.  The 
lower  fragment  is  often  rotated  upon  its  longitudinal  axis,  so  that 
the  foot  rests  upon  its  side,  while  the  upper  fragment  remains  un- 
disturbed by  rotation,  the  patella  looking  directly  upward  (see 
Fig.  476). 

The  swelling  will  vary.  It  may  be  extremely  slight  and  limited 
to  the  seat  of  the  fracture  or  it  may  extend  over  the  entire  leg. 
The  maximum  swelling  of  the  leg  is  usually  reached  three  or  four 


SYMPTOMS 


367 


days  after  the  accident.  If  the  fracture  was  caused  by  direct  vio- 
lence and  the  fragments  of  bone  are  sharp,  the  soft  parts  will  be 
damaged  and  the  resulting  hemorrhage  and  swelling  will  be  very 
considerable. 

Ecchyraosis  of  the  skin  appears  in  from  twenty-four  to  forty- 
eight  hours  after  the  accident ;  it  may  extend  over  the  whole  leg. 


Fig.  4S3.  —  Oblique  fracture  of  both 
bones  of  tlie  leg.  Displacement  of  the 
upper  fragments  in  the  same  inward  direc- 
tion (Massachusetts  General  Hospital,  749. 
X-ray  tracing). 


Fig.  4S4. — TiaiisN  crse  Iraclure  of  both 
bones  of  the  leg  at  the  middle ;  slight 
displacement  and  considerable  bowing 
(Massachusetts  General  Hospital,  1215. 
X-ray  tracing). 


Kcchymosis  from  a  sprain  is  localized  more  or  less  about  the  seat 
of  the  sprain;  that  from  a  fracture  is  often  extensive.  Blebs  or 
vesicles  may  appear  near  the  fracture  during  the  first  week  if  the 
swelling  is  great.  It  is  necessary  to  exercise  great  caution  in  the 
care  of  these  blebs,  that  they  do  not  become  infected. 

Fracture  of  the  shaft  of  the  fibula  may  be  very  obscure,  but 
pressure  upon  the  fibula  toward  the  tibia  will  elicit  pain  and 


368 


FRACTl'RES    OK    TIIU    LEO 


crepitus.  In  separation  dI  the  lower  c])iphvsis  of  the  tibia  the 
preservation  of  the  normal  relations  between  the  malleoli  is  of 
considerable  diagnostic  importance. 

Treatment. — For  purposes  of  treatment   fractures  of  the  leg 
are  arranged  into  several  distinct  groups — viz. : 

1.  Fractures  with  little  or  no  swelling  or  displacement. 

2.  I'Vactures  with  considerable  swelling. 

3-   Fractures  with  a  displacement  of  fragments  difficult  to  hold 
corrected. 

4.  Open  fractures. 


Fig.  4S5.— Double  fracture  of  the  tibia. 
Single  fracture  of  the  fibula  (Massachusetts 
General  Hospital,  1055.     X-ray  tracing). 


Fig.  486. — Fracture  of  the  fibula  with- 
out injury  to  the  tibia  (Massachusetts 
General  Hospital,  1230.    X-ray  tracing). 


The  indications  to  be  met  by  treatment  in  each  of  these  groups 
are  correction  of  deformity,  immobilization  of  fragments,  and 
restoration  of  the  limb  to  its  normal  condition. 

Fractures  with  Little  or  No  Displacement  or  Szuclling. — Fractures 
of  the  tibia  alone  or  the  fibula  alone  are  properly  placed  in  this 
group.  Fractures  of  both  bones  occasionally  occur  with  little  or 
no  displacement  and  with  but  a  trifling  amount  of  swelling.  In 
these  cases  the  leg  should  be  elevated  for  ten  minutes  in  order  to 
lessen  the  swelling.  The  foot,  leg,  and  lower  thigh  are  then 
bathed  with  soap  and  water,  and  thoroughly  dried  and  powdered. 


TREATMUNT 


369 


The  leg  being  properly  protected,  a  light  plaster-of- Paris  roller 
bandage  is  applied  from  the  toes  to  the  middle  of  the  thigh.  (See 
Details  of  Plaster  Work.)  The  leg  is  to  be  kept  elevated  for  the 
first  week  by  at  least  two  or  three  pillows.  If  good  judgment  is 
exercised  in  the  subsequent  care  of  the  case,  the  placing  of  such  a 
fracture,  as  previously  indicated,  immediately  in  a  plaster-of- Paris 
splint  is  attended  by  no  risk.  The  danger  lies  in  too  great  pressure 
upon  the  circulation,  caused  by  the  increasing  swelling  of  the  leg 
within  the  unyielding  plaster  splint.     Pressure  sores  and  gangrene 


Fig.  487. — Fracture  of  the  fibula  low 
•down  without  fracture  of  the  tibia  (X-ray 
tracing). 


Fig.  488. — Oblique  fracture  of  both 
bones  of  the  leg  low  down.  Fracture 
difficult  to  hold  in  good  position  (Massa- 
chusetts General  Hospital,  1024.  X-ray 
tracing). 


are  liable  to  result.  In  applying  the  splint  a  liberal  amount  of 
sheet  wadding  should  be  used.  The  condition  of  the  circulation 
should  be  noted  immediately  after  the  application  of  the  splint  and 
at  regular  intervals  thereafter  until  all  danger  from  undue  pressure 
lias  ceased.  Evidences  of  too  great  pressure  are  persistent  or 
increasing  swelling  of  the  toes,  blueness  of  the  toes,  and  pain.  It 
is  well,  in  order  to  avoid  undue  pressure  upon  the  leg,  to  split  the 
plaster  the  entire  length  of  the  splint  before  it  has  quite  hardened. 
The  splint  loses  by  this  procedure  none  of  its  immobilizing  quali- 
ties, for  it  can  be  bandaged  or  strapped  tightly  together  again. 
24 


370 


FRACTURES    OF    THE    LEG 


Too  great  pressure  upon  the  cireiikition  can  then  be  innnediately 
relieved  by  loosening  the  retaining  straps  or  bandage  and  thus 
opening  the  splint.  After  the  splint  has  been  on  the  leg  for  about 
a  week  and  a  half  or  two  weeks,  the  swelling  having  begun  to  sub- 
side, the  plaster  splint  will  become  loose  and  will  cease  to  hold  the 
fragments  firmly.     Unless  a  new  and  snug  splint  is  now  applied,  it 


Fig.  4S9. — Fracture  of  both  bones  of 
the  leg  from  bullet-wound.  Characteristic 
comminution  of  the  bones.  Bullet  not  re- 
moved. Recovery  with  a  useful  leg  (X-ray 
tracing)   (Warren). 


\ 


/ 


Fig.  490. — Transverse  fracture  of  the 
tibia,  high.  Direct  violence.  Great  swell- 
ing of  leg.  Threatening  gangrene.  Free 
incisions.  Leg  saved.  Result  good.  Same 
case  as  figure  491  (Massachusetts  General 
Hospital,  1064.     X-ray  tracing)  (Scudder). 


will  be  necessarv  to  cut  out  a  strip  of  plaster  an  inch  or  more  wide 
from  the  old  splint  to  admit  of  tightening.  During  the  changing 
of  the  plaster  splint  the  leg  should  be  steadied  by  an  assistant 
while  it  is  thoroughly  washed  with  soap  and  water  and  bathed 
with  alcohol. 

Fractures  with   Considerable   Immediate  Swelling. — Many  frac- 


TREATMENT 


371 


tures  are  not  seen  by  the  surgeon  until  two  or  three  hours  after 
they  have  occurred,  when  considerable  swelling  is  present.  As- 
sociated with  such  primary  swelling  there  will  be  laceration  of  the 
soft  parts  and  possible  extensive  injury  to  the  bone.  Blebs  filled 
with  clear  or  bloody  serum  may  be  present  about  the  seat  of  frac- 


^^ 

/1I 

■    -   --"' 

■ ■-.■^■t;^.  ,. 

'""-— 

Hv .: ' 

^^ 

A 

^BfeMi 

HH 

t»<t«^^^HHl 

Fig.  491. — Case  :  Closed  fracture  of  the  left  tibia.  Hematoma.  Impairment  of  the  circu- 
lation. Free  incisions.  Evacuation  of  blood.  Relief  of  pressure.  Leg  saved.  Recovery 
(Scudder). 


r  N  '^  1      V  "  ■**^jf'*^/-*^*  * 

- 

■ 

;« 

i^^i^^^^H 

Fig.  492. — Fracture  of  the  leg.     Temporary  or  emergencj- dressing.     Application  of  the  pillow 
with  straps.     Open  end  of  the  pillow-case  at  the  foot. 


ture.  These  should  be  evacuated  after  the  part  has  been  rendered 
surgically  clean  by  washing  with  soap  and  water  and  corrosive 
sublimate  solution,  and  then  dressed  with  a  dry  antiseptic  powder,, 
powdered  dermatol,  or  aristol.  Infection  may  take  place  through 
blebs.     Very  great  care  should  be  exercised  in  their  treatment- 


37 


FRACTURES    OF    THE    LEG 


Obviously,  it  is  unwise  immediately  to  apply  a  plastcr-of- Paris 
splint  to  cases  in  which  there  are  many  blebs  and  much  swelling. 
The  swelling  of  the  leg  may  become  so  great  that  the  life  of  the 
limb  may  be  at  stake,  the  danger  from  impending  gangrene  be- 
coming imminent.  In  such  cases  the  skin  of  the  leg  becomes  tense 
and  shiny,  tlie  leg  feels  hard  and  board-like,  pain  mav  be  extreme, 
and  the  toes  and  foot  become  slightly  blue.     The  hemorrhage,  be- 


Fig.  493. — Fracture  of  the  leg 


Pillow   and  side  splints  with   straps  and  towels.     Compare 
figure  494. 


> 1 


Fig.  494.— Fracture  of  the  leg.     Temporary  or  emergency  dressing.     Pillow,  side  splints,  and 
straps.     Pillow  held  by  shield-pins. 


ing  confined  beneath  the  fascia  and  skin,  causes  pressure  upon  the 
circulation.  The  circulation  in  the  leg  is  thus  impeded.  Under 
such  circumstances  operation  is  necessary  in  order  to  relieve  ten- 
sion and  to  check  hemorrhage.  Incisions  in  the  long  axis  of  the 
limb  through  skin  and  fascia  will  be  followed  by  a  rapid  decrease 
in  the  swelling  of  the  leg  and  a  cessation  of  the  pain.  After  inci- 
sion, the  bleeding  vessels  found  should  be  ligated.  The  bones  may 
be  sutured  at  this  time  if  it  is  thought  wise.     If  these  wounds 


TREATMIiNT 


373 


remain  aseptic,  they  may  be  closed  after  a  few  days  by  suture  or 
may  be  allowed  to  heal  openly.  This  method  of  treatment  will 
usually  result  in  saving  the  leg  (see  Figs.  490,  491).      If  the  circu- 


Fig.  495.— Diagram  of  oblique  fracture  of  the  leg.     Displacement  upward  and  forward  of  the 

lower  fragment. 


Fig.  496.— Diagram  illustrating  a  frequent  method  of  apparently  correcting  the  displacement, 
which  results  in  producing  a  backward  bowing. 


Fig.  497. — Diagram  illustrating  the  proper  direction  in  which,  combined  with  traction,  force 
should  be  exerted  in  order  to  correct  the  displacement. 


lation  does  not  return  and  gangrene  is  imminent,  immediate  am- 
putation of  the  limb  well  above  the  fracture  at  the  lower  or  middle 
third  of  the  thigh  is  the  only  procedure.     Traumatic  gangrene  is 


374 


FRACTURES   OF   THE    LEG 


often  rapidly  followed  by  general  septic  infection.  It  is  best  to 
use  a  temporary  dressing  in  cases  in  which  there  is  great  initial 
swelling  of  the  leg. 

llie  Temporary  Dressing. — The  Pillow  and  vSide  .Splints. — The 
leg  is  placed  on  a  pillow  covered  with  a  pillow-case;  straps  are 
placed  under  the  pillow  and  drawn  snugly  up  about  the  leg  (see 
Fig.  492).  The  edges  of  the  pillow  are  rolled  in  against  the  leg  for 
firmness,  ^arrowly  folded  towels  are  placed  between  the  leg  and 
the  straps.  The  straps  are  then  drawn  tighter.  The  open  end  of 
tlie  pillow-case  is  folded  and  pinned  under  the  sole  of  the  foot. 
Three  pieces  of  splint  wood  are  introduced  between  the  pillow  and 
straps — one  is  slipped  underneath  and  one  upon  each  side  of  the 
pillow.     The  pillow  thus  serves  as  a  padding  for  the  box  formed 


Fig.  498.— Padding  the  Cabot  posterior  wire  splint.     Applying  sheet  wadding.     The  shape 
and  proportions  of  the  Cabot  splint  are  apparent. 


bv  the  Splint  wood  (see  Fig.  493).  Ice-bags  may  be  conveniently 
placed  along  the  anterior  surface  of  the  leg  between  the  edges  of 
the  pillow^  Thev  relieve  pain  and  are  said  to  check  hemorrhage 
immediately  after  the  fracture.  If  greater  security  is  thought 
necessary,  the  pillow-case,  instead  of  having  its  sides  rolled  in, 
may  be  pinned  with  shield-pins  up  over  the  anterior  surface  of 
the  leg  (see  Fig.  494). 

This  temporary  dressing  is  left  in  place  for  a  week  or  a  week  and 
a  half.  The  swelling  will  then  have  partly  subsided.  If  at  this 
time  there  is  little  or  no  swelling  and  the  displacement  is  slight,  a 
plaster-of-Paris  splint  may  be  applied  as  a  permanent  dressing;  it 
is  split  or  not  as  circumstances  indicate.  If,  on  the  other  hand,  at 
the  end  of  a  week  or  a  week  and  a  half  it  is  desired  to  have  the 


TREATMENT 


375 


fracture  open  to  inspection  and  more  directly  accessible  and  under 
the  eye  of  the  surgeon,  then  the  posterior  wire  and  side  splints 
should  be  applied. 

The  Permanent  Dressing  for  Fracture  of  the  Leg. — vSeveral  im- 
portant things  are  to  be  kept  constantly  in  mind  in  placing  a  frac- 


Fig.  499.— Padding  the  Cabot  posterior  wire  splint:  (i)  With  sheet-wadding  (see  Fig. 
498)  ;  (2)  with  a  cotton  roller  around  the  wire,  and  (3)  around  both  wires,  to  form  a  back  to 
the  splint. 


tured  leg  in  a  permanent  splint.  They  are  as  follows :  The  aline- 
ment  of  the  bones  of  the  leg  is  to  be  maintained ;  rotation  of  either 
fragment  upon  its  long  axis  is  to  be  avoided ;  the  foot  is  to  be  kept 
extended  to  a  right  angle  with  the  leg;  lateral  deviation  is  to  be 
avoided;  the  inner  side  of  the  great  toe,  the  middle  of  the  patella, 
and  the  anterior  superior  spine  of  the  ilium  should  be  in  one 


376  FRACTURES    OF    THE    LEG 

straight  line;  anteroposterior  deformity  is  to  be  avoided  (the  con- 
vexity of  this  curve  of  deformity  is  usually  backward ;  it  is  a 
hyperextension  of  the  leg  at  the  seat  of  fracture)  (see  Figs.  495- 
497);  frequent  measurements  and  inspection  of  the  leg  should  be 
made;  inspection  should  be  made  not  only  from  the  front,  but 
lalerallv  as  well;  readjustment  of  apparatus  is  necessitated  by 
changed  in  the  position  of  the  bones. 

The  Posterior  Wire  and  Side  vSplints. — The  posterior  wire  or 
Cabot  splint  is  made  of  iron  wire  the  size  round  of  an  ordinary 
lead-pencil  (see  Fig.  498).  It  is  applied  to  the  back  of  the  foot, 
leg,  and  thigh,  extending  from  just  beyond  the  tips  of  the  toes 
to  above  the  middle  of  the  thigh.     It  is  narrow  at  the  heel  and 


Fig.  500.— The  Cabot  posterior  wire  splint  padded  completely.     Note  the  foot-pad  of  paste- 
board covered  by  cotton  cloth  pinned  to  the  foot-piece  of  the  splint  for  greater  security. 


broad  enough  above  to  permit  the  thigh  to  rest  comfortably 
upon  it.     The  foot-piece  is  at  right  angles  to  the  leg. 

Having  at  hand  the  iron  wire  the  size  of  an  ordinary  lead- 
pencil,  this  splint  can  be  quickly  and  easily  made  by  means  of  a 
vise  for  holding  the  wire,  and  a  wrench  for  grasping  the  wire  while 
bending  it.  The  two  free  ends  of  the  wire  of  the  splint  may  be 
held  firmly  together  by  having  them  overlap  and  binding  them 
together  with  small-sized  copper-wire.  These  free  ends  may,  of 
course,  be  held  by  solder. 

The  Covering  of  the  Posterior  Wire  vSplint. — The  wire  is  wound 
first  with  a  roller  of  sheet  wadding,  then  with  a  cotton  roller,  and 
finally  a  cotton  roller  bandage  is  wound  about  both  sides  of  the 
splint  so  as  to  make  a  posterior  surface  upon  which  the  leg  may 
rest  (see  Figs.  498,  499,  500 j. 


TREATMENT  377 

The  side  splints  of  wood  (see  Fig.  501)  should  be  about  four 
inches  wide,  and  long  enough  to  extend  from  the  foot-piece  to  the 
top  of  the  splint.  The  splints  may  be  covered  with  sheet  wad- 
ding and  cotton  cloth,  as  seen  in  the  figure. 

Care  of  the  Heel. — If  but  slight  pressure  is  maintained  upon  the 
heel  even  for  a  few  days,  a  pressure  sore  will  develop.      This  is 


Fig.  501. — Side  splint  of   splint  wood.     Method  of  padding:    (i)  With  sheet-wadding;    {2) 
with  cotton  cloth  ;  (4)  pinned  in  place,  and  then  (5)  stitched. 


liable  to  increase  to  a  considerable  size.  It  is  very  slow  in  healing. 
Many  weeks  after  the  fracture  of  the  leg  has  united  the  pressure 
sore  may  be  open.  It  is,  therefore,  of  very  great  importance  to 
prevent  pressure  upon  the  heel  during  the  treatment  of  fractures 
of  the  lower  extremity  associated  with  dorsal  decubitus.  There 
are  four  methods  of  avoiding  pressure  on  the  heel.     Position  will 


378 


FRACTURES    OF    THE    LEG 


assist  materially.  The  position  of  the  foot  largely  determines  the 
amount  of  pressure  falling  on  the  heel.  When  the  foot  rests 
nalurallv,  it  is  in  the  position  of  slight  plantar  flexion.  The  heel 
presses  firmly  upon  the  splint  (see  Fig.  502).  A  large  part  of  the 
weight  of  the  leg  thus  falls  upon  the  heel.  When  the  foot  is  ex- 
tended to  a  right  angle  with  the  leg,  the  pressure  upon  the  heel  is, 
in  a  large  measure,  removed  (see  Fig.  503).  Therefore,  in  putting 
up  fractures  of  the  leg  the  right-angle  position  is  the  desirable  one. 


Fig.  502. — Normal  leg  with  foot  flexed,  showini;  Uuil  \.h<j  licel  ixst^j  heavily  on  the  table  (see 

Fig.  503). 


Fig.  503. — Posterior  outline  of  the  normal  leg,  suggesting  the  necessary  padding  to  be 
used  on  the  Cabot  splint.  When  the  foot  is  at  a  right  angle  with  the  leg,  the  heel  rests 
lightly  on  the  table. 


Padding  above  the  heel  is  of  service.  The  ring  or  doughnut  pad 
around  the  heel  is  sometimes  efficient.  Slinging  the  foot  by  adhe- 
sive straps  applied  to  the  sides  of  the  heel  and  foot  and  fastened 
to  the  foot-piece  of  the  splint  is  a  very  satisfactory  method  of  re- 
moving pressure  from  the  point  of  the  heel  (see  Fig.  504). 

The  Padding  of  the  Posterior  Wire  Splint  for  the  Reception  of 
the  Lower  Extremity. — Regard  should  be  had  for  the  natural 
curves  of  the  leg  and  thigh  posteriorly  (see  Fig.  503).  Above  the 
heel,  behind  the  knee,  and  below  the  buttock  are  distinct  hollows, 


TRPCATMUNT 


379 


at  which  places  the  padding,  as  indicated  in  the  illustration, 
should  be  thicker  than  at  other  points.  Regard  should  likewise 
be  had  for  the  natural  lateral  curves  of  both  thigh  and  leg.  Just 
below  the  malleoli,  above  the  ankle,  below  the  knee,  and  above 
the  knee  are  distinct  hollows  that  will  require  more  padding  than 
elsewhere  on  the  sides  of  the  limb  (see  Fig.  505).  The  more  care- 
fully the  splint  is  padded,  the  more  nearly  perfect  will  be  the  re- 
sult of  treatment  and  the  greater  will  be  the  comfort  of  the  patient. 


Fig.  504. — Method  of  supporting  the  foot  in  fractures  of  the  leg  when  using  a  posterior  splint. 
a,  Padding  beneath  tendo  Achillis;  i^,  ring  under  heel ;  c,  sling  of  adhesive  plaster. 


The  leg  is  to  be  placed  upon  the  posterior  iron  splint,  so  padded 
posteriorly  that  it  rests  naturally  and  comfortably.  The  foot 
should  be  placed  at  a  right  angle,  drawn  down  snugly  to  the  foot- 
piece,  and  steadied  by  adhesive-plaster  straps  carried  around  the 
foot  and  splint  in  a  figure-of-eight  bandage  (see  Figs.  508,  509). 
The  side  splints,  so  padded  with  pillow-cases  or  towels  as  to  bring 
suitable  pressure  upon  the  leg  and  thigh,  are  applied  and  held  in 
position  by  straps  and  buckles  (see  Fig.  509).     This  splint  immob- 


38o 


FRACTURES    OF    THE    LEG 


ilizes  the  knee  and  ankle-joints  and  the  fractured  bones.  The 
region  of  the  fracture  is  open  to  inspection  anteriorly.  Lateral 
inspection  is  facilitated  by  loosening  the  straps  and  lowering  the 
side  splints.  Anv  deviation  from  the  normal  lines  of  the  leg  can 
be  adiusted  easilv.     At  the  end  of  three  weeks,  when  the  fracture 


Fig.  505. — X-ray  of  fracture  in  child  of 
eight  years.  Fracture  difficult  to  hold  re- 
duced.    Bones  sutured.     E.xcellent  result. 


Fig  506. — Fractures  of  the  leg.  Cabot 
posterior  wire  splint  and  side  splints,  show- 
ing the  space  to  be  padded  on  each  side  of 
the  leg  and  thigh. 


is  uniting  and  the  callus  is  still  soft,  the  leg  should  be  removed 
from  the  splint  and  examined  carefully  from  the  front,  from  the 
back,  and  laterally  for  any  deviation  from  the  normal.  If  any 
deviation  is  discovered,  it  should  be  corrected  and  the  leg  put 
again  into  a  posterior  wire  splint  or  into  a  removable  plaster-of- 
Paris  splint. 


At  the  foot. 


Suspension 
hooks. 


At  the  knee 


Suspension 
hooks. 


Fig.  507. — The  anterior  wire  suspensory  apparatus  of  N.  R.  Smith.  This  splint  is  applied 
to  the  anterior  surface  of  the  padded  foot,  leg,  thigh,  and  hip.  The  splint  is  fixed  to  the  leg 
by  a  bandage.  The  splint  is  intended  to  immobilize  the  leg  and  at  the  same  time  to  suspend 
it,  permitting  motion  at  the  hip,  and  to  secure  extension  upon  the  distal  fragments. 


Fig.  508. — Fracture  of  the  leg.     Cabot  posterior  wire  splint  padded  properly  according  to  the 
curves  of  the  normal  leg.     Notice  that  the  heel  is  free  from  the  splint  (see  Fig.  503). 


Fig.  509.- 


-Fracture  of  the  leg.     Cabot  posterior  wire  splint,  side  and  posterior  wooden  splints 
held  by  straps.     Adhesive  plaster  to  foot  and  ankle. 


381 


38: 


FRACTURES   OF   THE   LEG 


The  first  night  after  putting  up  the  fracture  the  patient  will 
probably  be  uncomfortable.  The  new  and  restrained  position, 
the  after-effect  of  the  anesthetic  if  one  has  been  used,  the  points 
of  undue  pressure  yet  to  be  adjusted,  the  itching  of  the  skin,  the 


Fig.  5:0. — Short-Desault  splint  for 
the  application  of  traction  to  lower  leg 
fractures.  Fracture  at  X.  Extension 
strips  up  from  the  fracture  are  fastened 
at  the  top  of  the  sjilints.  Extension 
strips  do-cvtt  from  the  fracture  are  fast- 
ened to  the  foot-piece.  Tightening  the 
screw  at  fool-piece  makes  traction  and 
countertraction. 


Fig.  511. — Plaster  traction  splint  :  a,  Appli-. 
cation  of  adhesive-plaster  extension  strips  as. 
in  figure  510  ;  b,  plaster  bandage  allowing  exit 
of  extension  straps.  Note  space  left  below  the- 
sole  to  allow  for  efTective  traction  and  buckles 
to  which  the  upper  extension  is  attached. 


inability  to  move  about,  the  necessity  of  lying  in  one  position, 
actual  pain  at  the  seat  of  the  fracture — all  combine  to  make  life 
miserable.  It  will  be  a  wise  precaution  on  the  part  of  the  attend- 
ant if  a  little  morphin  is  administered  subcutaneously  this  first. 


TREATMENT  383 

night,  as  patient,  nurse,  and  physician  will  rest  better.  After  the 
first  night  there  will,  under  ordinary  circumstances,  be  no  especial 
difficulty.  After  the  plaster  splint  is  applied  the  vSmith  anterior 
wire  splint  attached  to  the  anterior  surface  of  the  thigh,  leg,  and 
dorsum  of  the  foot  often  will  enable  the  leg  to  be  slung  just  so  as  to 
clear  the  bed.  This  position  is  one  of  considerable  comfort.  The 
patient  is  enabled  to  move  in  bed  a  little  and  to  change  his  position 
without  disturbing  the  fracture.  This  anterior  wire  splint  is  made, 
like  the  Cabot  posterior  wire  splint,  of  iron  wire,  but  is  fitted  to 
the  anterior  surface  of  the  foot,  leg,  and  thigh  (see  Fig.  507). 

Fractures  Difficult  to  Hold  Reduced. — These  are  usually  oblique 
fractures  of  the  tibia,  occurring  most  often  in  the  lower  half  of  the 


Fig.  512. — Cabot  posterior  wire  splint,  as  used  for  open  fractures  (lateral  view).  Note 
protective  padding  of  splint  beneath  wound,  X,  to  facilitate  dressings  without  the  removal  of 
the  leg  from  the  splint. 


bone  (see  Fig.  505).  The  nearer  to  the  ankle-joint  the  fracture  is, 
the  greater  is  the  likelihood  of  a  displacement  which  is  hard  to 
hold  reduced.  The  contraction  of  the  quadriceps  extensor  tends 
to  pull  the  upper  fragment  forward,  the  contraction  of  the  gastroc- 
nemius tends  to  pull  the  lower  fragment  backward  and  upward. 
The  obliquity  of  the  fracture  and  the  action  of  these  two  groups  of 
powerful  muscles  make  it  almost  an  impossibility  to  hold  these 
fractures  reduced.  It  is  often,  even  under  an  anesthetic,  impos- 
sible to  correct  the  deformity  without  doing  a  tenotomy  of  the 
tendo  Achillis.  A  posterior  wire  and  side  splints  with  the  foot 
held  fixed,  with  a  moderate  traction  and  pads  placed  at  the  seat  of 
fracture,  may  be  of  service. 

A  plaster-of- Paris  splint  with  extension  and  counterextension,. 


3S4 


FRACTURES    OK    THE    LEG 


after  the  ])rinciple  of  the  .Short-Desault  apparatus  and  aceording 
to  Lovett's  adaptation  (see  Figs.  510,  511),  will  hold  some  of  the 
more  difficult  cases. 

Method  of  Application  of  the  Traction  Plaster-of- Paris  Splint. — 
From  the  seat  of  fracture  running  upward  and   from  the  seat 


F^g-  513- — Cabot  wire  splint  in  open  fractures,  viewed  from  above.  Leg  in  position  ; 
wound  of  soft  parts  seen  ;  dressing  removed  ;  side  splints  and  straps  seen.  Upper  and  lower 
fragments  held  by  permanent  bandages  during  inspection  of  the  wound. 


of  fracture  running  downward  are  applied  extension  adhesive 
plasters,  with  webbing  attachments,  as  seen  in  the  diagram  (see 
Fig.  511).  Below  the  foot,  the  size  of  the  sole  of  the  foot  and  two 
inches  thick,  is  held  a  very  firm  pad  of  sheet  wadding.  A  plaster 
bandage  is  applied  to  the  leg,  according  to  the  usual  methods,  from 


TREATMENT 


385 


the  toes  to  above  the  knee.  A  buckle  kjoking  upward  is  incor- 
porated in  the  plaster  bandage  upon  each  side  of  the  leg  a  little 
above  the  level  of  the  knee.  A  slit  is  left  upon  each  side  of  the 
ankle  for  the  lower  extension  webbings  to  come  through  (see  Fig. 
511).  After  the  plaster  has  hardened  the  sheet- wadding  foot-pad 
is  removed.  The  upper  extension  straps  are  pulled  snugly  over 
the  upper  edge  of  the  plaster  splint  and  fastened  to  the  buckles  on 
each  side.  Then  the  lower  straps  are  pulled  taut  over  the  foot- 
piece  of  the  plaster.     Countertraction  and  traction  are  thus  main- 


Fig.  514.- 


-Fracture  of  both   bones  of  the  leg.     Ununited  fracture  of   tibia. 
(Massachusetts  General  Hospital,  1190.    X-ray  tracing). 


Fibula   united 


tained  upon  the  fragments  of  the  fracture.  A  window  is  cut  in 
the  plaster  to  observe  the  position  of  the  bones.  This  apparatus 
is  efficient  in  many  instances  in  which  it  is  otherwise  difficult  to 
maintain  reduction. 

Operative  interference  with  suture  of  the  fragments  of  bone  is 
the  most  effective  method  of  treatment  in  troublesome  cases.  It 
is  always  wise  to  delay  operating  until  after  the  primary  effects 
of  the  injury  have  ceased — that  is,  until  after  the  acute  swelling 
has  subsided  and  the  damaged  tissues  have  had  time  to  recover 
themselves.     A  delay  of  ten  days  is  time  gained.     During  these 

25 


386  FRACTURES    OF    THE    LEG 

ten  days  some  one  of  Ihc  methods  already  mentioned  may  suc- 
ceed in  holding  the  fracture  satisfactorily  so  that  operation  is 
unnecessary. 

Treatment  of  Open  Fractures  of  the  Leg. — Treatment  rests  upon 
the  presumption  that  every  open  fracture  is  infected.  The  object 
of  treatment  is  to  convert  the  oj^en  infected  fracture  into  a  closed 


Fig-  5I5-— Open  fracture  of  both  bones  of  the  right  lejj  in  the  lower  third,  six  montlis  after  the 
accident.    Note  the  deformity  and  enlargement  of  the  leg  near  the  ankle. 

noninfected  fracture.  It  is  important  that  the  first  dressing  of 
the  wound  should  be  a  clean  one.  If  it  is  a  temporary  dressing, 
the  wound  should  be  douched  with  boiled  water,  covered  with  a 
clean  absorbent  dressing,  and  the  leg  placed  upon  a  pillow  splint. 
The  Permanent  Dressing. — Every  open  fracture  of  the  leg 
should  be  anesthetized  for  careful  examination,  diagnosis,  and  the 


TREATMENT  OF  OPEN  FRACTURES 


387 


initial  dressing.  The  leg  should  be  washed  with  soap  and  water 
and  scrubbed  with  a  gauze  sponge  or  soft  nail-brush.  The  leg 
should  be  shaved  of  all  hair  in  the  vicinity  of  the  wound,  and 
should  then  be  washed  with  liquid  sodae  chlorinatai  (chlorinated 
soda),  one  part  to  twenty.  This  will  most  effectually  free  it  from 
all  grease  and  oily  dirt. 

The  Wound  of  the  vSoft  Parts. — This  should  be  moderately  en- 
larged to  allow  easy  access  to  its  deeper  parts.  There  are,  no 
doubt,  cases  of  fracture  of  the  bones  of  the  leg  open  from  within 


Fig.  516. — Lateral  view  of  figure  515.    Note  discharging  sinuses. 


outward  in  which  the  wound  is  small,  evidently  made  by  the  bone, 
in  which  it  is  prudent  to  seal  the  wound  and  to  regard  the  likeli- 
hood of  infection  as  absent.  These  cases,  chosen  in  the  judgment 
of  a  wise  surgeon,  may  do  well,  but  they  may  not ;  therefore,  the 
author  believes  it  is  safer  to  advise  that  all  wounds  of  open  frac- 
tures be  enlarged  for  thorough  cleansing.  The  blood-clot  and 
detritus  should  be  washed  out  by  irrigating  with  a  warm  solution 
of  corrosive  sublimate,  i  :  5000.  Irrigation  should  be  supple- 
mented by  thorough  scrubbing  of  the  tissues  of  the  wound  by 
small  gauze  swabs  held  in  forceps.     These  swabs  should  be  small 


388 


FRACTURES    OF    THE    LEG 


enough  to  be  carried  into  all  the  recesses  of  the  wound.  All  bleed- 
ing should  be  checked.  Loose  bits  of  muscle,  fat,  fascia,  and  bone 
should  be  removed.  Often  the  finger  will  detect  bits  of  bone 
when  the  forceps  will  not.     The  firmly  attached  fragments  of  bone 


Fig.  517. — Ligaments  of  normal  ankle.  The 
mortise  for  the  astragalus  is  seen. 


Fig.  518. — Pott's  fracture  (diagram). 
Fracture  of  fibula,  tear  of  the  internal 
lateral  ligament.  Displacement  outward 
of  foot.  A  sliding  of  the  astragalus  upoti 
the  articular  surface  of  the  tibia  without  a 
tilting  of  the  astragalus  upon  its  antero- 
posterior axis. 


are  to  be  left  undisturbed.  Regarding  the  treatment  of  the 
slightly  fixed  fragments  of  bone,  the  surgeon  must  judge  in  each 
instance.  It  is  a  good  rule  when  in  doubt  about  the  viability  of  a 
fragment  of  bone  to  remove  it.     The  deep  fascia  may  need  division 


TREATMENT  OF  OPEN  FRACTURES 


389 


to  permit  of  a  view  of  the  depths  of  the  wound.  The  fractured 
bones  are  then  to  be  approximated  and  sutured,  if  practicable. 
The  corners  of  the  wound  may  be  sutured.  It  is  wise  to  leave  the 
wound  open  enough  to  receive  several  temporary  gauze  wicks  for 
drainage  during  the  first  few  days.  Counteropenings  may  be 
needed  if  one  is  not  sure  of  the  aseptic  condition  of  the  wound. 
They  do  no  harm  and  may  prove  safety-valves  against  latent  in- 
fection. Before  leaving  the  wound  it  should  be  thoroughly 
douched  with  boiled  water.  An  aseptic  dressing  is  applied,  and 
the  leg  is  immobilized  by  the  posterior  wire  and  side  splints  (see 
Figs.  512,  513)  or  is  put  up  immediately  in  a  plaster-of- Paris  splint. 


Fig.  519. — Case  :  Open  Pott's  fracture.     Wound  in  soft  parts  and  protruding  tibia  to  be  seen. 


If  the  plaster-of- Paris  splint  is  used,  a  window  should  be  cut  in  it, 
through  which  the  wound,  if  left  unsutured  in  part,  may  be  dressed. 
Care  of  a  Fracture  of  the  Leg  after  the  Permanent  Dressing  has 
been  Applied. — All  fractures  of  the  leg  will  be  placed,  sooner  or 
later,  in  the  fixed  plaster-of- Paris  splint.  One  week  after  the 
splint  is  applied  the  patient  may  be  up  and  about  with  crutches. 
At  first,  the  hanging  of  the  leg  down  may  be  attended  by  great  dis- 
comfort. There  may  be  a  sense  of  fullness  and  of  burning  in  the 
leg.  The  leg  may  feel  as  if  it  would  burst.  The  toes  may  look 
blue  and  be  swollen.  As  the  patient  becomes  accustomed  to  these 
conditions,  which  are  in  themselves  harmless,  he  will  be  able  to 
ignore  them;  they  will  grow  less  and  less  troublesome,  and  even- 
tually disappear.     At  the  end  of  four  or  five  weeks  the  fracture 


390 


FRACTURES    OF    THE    LEG 


should  be  found  lirudy  united.  A  lighter  plaster  splint  may  be 
applied,  extending  onlv  to  the  knee-joint,  and  allowing  flexion  of 
the  knee.  This  thin  j^lastcr  splint  should  be  split,  so  as  to  be  re- 
moval)le.  After  about  four  weeks  the  leg  should  then  receive  a 
daily  bath  and  massage,  with  active  and  passive  motion  to  the 


Fig.  520.— Normnl  leg  and  foot  at  a  right  angle.     Note  the  relative  position  of  heel  and  leg. 


Fig.  521.— Pott's  fracture.  Posterior  displacement  of  the  foot  on  the  leg.  Note  the  short- 
ening of  the  foot  from  the  toe  to  the  front  of  the  ankle.  Compare  the  relative  position  of  the 
heel  and  leg  with  the  same  in  figure  520. 


knee-joint.  At  about  the  eighth  week  the  protecting  splint  may 
be  removed,  a  flannel  bandage  from  the  toes  to  the  knee  substi- 
tuted, and  the  patient  be  allowed  to  touch  the  foot  to  the  floor, 
bearing  a  little  weight.  As  soon  as  the  plaster  is  removed  and  the 
bandage  substituted,  a  shoe,  preferably  laced,  should  be  worn  on 


TREATMENT   OF   OPRN    FRACTURES 


391 


that  foot.  From  the  tenth  to  the  twelfth  week  after  the  injury 
the  patient  should  be  walking  with  a  cane.  According  to  present 
methods,  a  fractured  leg  would  require  from  three  to  five  months 
of  treatment  before  restoration  to  normal  function  is  completed. 
The  after-care  of  a  case  of  fracture  of  the  leg  is  attended  with  no 
little  anxiety  on  the  part  of  the  surgeon.  The  general  health  of 
the  patient  is  a  matter  of  considerable  concern.  The  loss  of  exer- 
cise entailed  by  the  cramped  and  unnatural  position  causes  loss  of 


■pig.  522. — Pott's  fracture  of  left  ankle.    Method  of  examining  ankle.    Lateral  mobility  shown. 
Note  the  grasp  of  the  foot  and  the  leg. 


appetite,  headache,  constipation,  dyspeptic  ills,  etc.  The  pain 
through  the  whole  limb,  due  undoubtedly  to  the  sprain  and 
wrenching  at  the  time  of  the  injury,  the  aching  at  night  at  the  seat 
•of  the  fracture,  combine  to  render  the  patient  thoroughly  uncom- 
fortable, unhappy,  and  even  melancholy.  Pressure  spots  will 
appear  about  the  most  carefully  applied  bandage,  and  they  must 
receive  attention.  Itching  of  the  skin  inside  the  splints  is  some- 
times almost  unendurable.     To  every  patient  daily  general  and 


.i9^ 


FRACTX'RES    OF    THE    LEG 


local  massage  and  bathing  will  be  found  to  be  of  unspeakable  com- 
fort. The  average  hospital  patient  is  far  less  sensitive  to  all  the 
pettv  annovances  of  an  immovable  and  closely  fitting  dressing 
than  is  the  private  patient. 

The  Prognosis. — In  children  and  ^■()ung  people  the  minimum 
time  is  consumed  bv  the  process  of  repair.  The  restoration  of 
the  leg  to  its  normal  function  is  more  rapid  than  in  the  cases  of 
adults,  and  there  are  fewer  complications.  In  adults  a  chronic 
arthritis  may  appear  in  the  neighboring  knee-  or  ankle-joints. 
vSwelling  of  the  leg  and  ankle  may  persist  for  some  time.  Non- 
union of  the  bones  may  result,  and  necessitate  operative  measures 
(see  Fig.  514).      If  the  fracture  is  oblique,  shortening  mav  occur 


Fig.  523. — Case  :  Fracture  of  the  internal  and  external  malleoli  and  displacement  of  the  foot 

inward  and  backward. 


even  after  union  takes  place  if  the  unsupported  leg  is  used  too- 
soon  and  too  much.  If  the  wound  of  an  open  fracture  heals 
quickly,  and  there  is  little  comminution  of  bone,  repair  will  take 
place  as  in  a  closed  fracture.  Otherwise,  an  open  fracture  will 
unite  more  slowly  than  a  closed  fracture.  Persistent  swelling  of 
the  leg,  particularlv  about  the  ankle,  is  associated  with  the  con- 
valescence from  an  open  fracture.  Necrosis  of  bone  at  the  seat  of 
fracture  may  occur  in  cases  of  open  fracture  even  many  months  or 
years  after  the  original  injury.  Abscesses  and  sinuses  may  form, 
necessitating  operation  for  the  removal  of  the  necrosed  bone  (see 
Figs.  515,  516).  If  the  fracture  is  near  the  knee  or  ankle-joints,  the 
prognosis  is  more  uncertain  than  if  the  fracture  is  at  the  center 


RESULTS  AFTER  TREATMENT 


39.^ 


of  the  shaft.  A  comminuted  fracture  is  more  hkely  to  be  longer 
in  uniting  and  to  give  rise  to  trouble  after  repair  than  is  a  single 
transverse  fracture. 

Results  after  Fractures  of  the  Leg. — Of  value  in  this  connec- 
tion are  the  results  following  fracture  of  the  leg  in  thirty-five  cases 
treated  at  the  Massachusetts  General  Hospital,  and  examined 
one  and  a  half  to  ten  years  after  the  accident.     In  the  detailed 


Fig.  524. — Same  as  figure  523.     Lateral  displacement  of  foot  inward  (see  X-ray  tracing, 

Fig.  525)- 


report  of  these  cases  the  exact  lesion  and  its  seat  will  be  stated. 
In  thirteen  cases — in  ten  of  which  the  age  was  forty-two,  the  rest 
under  thirty — the  result  reported  was  that  the  injured  leg  was  ' '  as 
good  as  the  other  leg."  In  twenty-two  cases  the  result  was  a  leg 
permanently  impaired  in  some  particular.  vSome  cases  had  fiat- 
foot,  deformity  of  the  leg,  limited  motion  at  the  knee-joint,  lame- 
ness, necrosis  of  bone,  pain  in  the  fracture  when  the  weather  was 


394  FRACTURES   OF    THE    LEG 

damp.  Other  cases  had  pain  in  the  leg  upon  standing,  stiffness  of 
the  ankle,  pain  upon  stepping  on  uneven  surfaces,  weakness  of  the 
leg,  swelling  of  the  leg  and  foot,  cramps  at  night  in  the  calf  of  the 
leg,  or  some  combination  of  these  symptoms. 

Thrombosis  and  Ewbolism. — Thrombosis  of  the  veins  about  a 
fracture,  and  particularly  about  a  fracture  in  which  there  is  some 
laceration  of  the  soft  parts,  is  not  at  all  uncommon.  At  times, 
and  rather  more  frequently  than  is  generally  supposed,  emboli  are 
detached  from  these  thrombi  and  cause  almost  immediate  death, 
with  svmptoms  of  pulmonary  embolism — namely,  a  sudden  cyano- 
sis and  great  difficultv  in  breathing  associated  with  intense  pre- 
cordial distress. 

Thrombosis  of  the  veins  of  the  leg  or  thigh  is  undoubtedly  one 
of  the  causes  of  the  great  edema  seen  after  fracture  of  these  parts. 

Rcjractnrc  of  the  Bones  of  the  Lower  Extremity. — It  is  not  an  un- 
common experience  to  find  that  a  patient  with  a  fracture  of  the 
thigh,  leg,  or  patella  refractures  the  partially  united  bone.  This 
refracture  is  due  to  either  muscular  violence  or  a  slight  fall.  There 
is  ordinarilv  little  displacement  of  the  fragments.  The  callus  of 
the  original  injury  holds  the  bones  quite  securely.  The  leg  is 
usuallv  bent  at  the  seat  of  the  fracture.  Refracture  is,  therefore, 
practicallv  a  fracture  of  callus.  This  accident  has  even  occurred 
while  the  patient  is  wearing  a  protective  splint  of  plaster-of- Paris. 
Union  in  these  cases  is  much  more  rapid  than  after  the  original 
injurv.  About  one-half  the  time  required  for  union  of  the  original 
fracture  is  necessary  for  union  of  the  refracture.  The  patient 
mav,  therefore,  be  much  encouraged,  for  though  the  accident  of 
refracture  is  a  disheartening  one,  yet  he  will  not  be  obliged  to  look 
forward  to  a  long  confinement. 


POTT'S  FRACTURE 
Anatomy. — The  anatomical  relations  of  the  lower  ends  of  the 
fibula  and  tibia  and  the  astragalus  and  os  calcis  should  be  kept 
constantlv  in  mind.  The  os  calcis  and  astragalus  are  held  firmly 
together,  forming  the  posterior  portion  of  the  foot.  The  astraga- 
lus rests  mortise-like  between  the  internal  and  external  malleoli 
(see  Fig.  517).     The  strength  of  the  inferior  tibiofibular  articula- 


POTT'S    FRACTURE 


395 


lion  depends  upon  the  strong  inferior  tibiofibular  ligaments,  par- 
ticularly upon  the  interosseous  ligament. 

By  Pott's  fracture  of  the  ankle  is  understood  the  injury  caused 
by  forcible  eversion  and  abduction  of  the  foot  upon  the  leg.  The 
lesions  which  may  be  present  in  this  fracture  are  a  rupture  of  the 
internal  lateral  ligament,  a  fracture  of  the  tip  of  the  internal 
malleolus,  a  separation  of  the  lower  tibiofibular  articulation,  an 
oblique  fracture  of  the  fibula  two  or  three  inches  above  the  tip  of 
the  external  malleolus,  a  fracture  of  the  outer  edge  of  the  lower  end 


Internal  malleolus. 
Astragalus. 


) 


I  Internal  malleoli 


Scaphoid. 


Fig.  525. — Fracture  of  both  malleoli  (anteroposterior  view).  Inversion  of  foot  (X-ray  tracing). 


of  the  tibia.  Ordinarily,  the  mechanism  of  the  fracture  is  some- 
what as  follows:  As  the  foot  is  abducted,  the  strain  is  felt  at  the 
internal  lateral  ligament  and  at  the  inferior  tibiofibular  interos- 
seous ligament,  and  these  give  way.  If  the  force  continues,  the 
fibula  breaks  (see  Fig.  518).  If  the  force  still  continues,  the  inter- 
nal malleolus  is  pushed  through  the  skin,  and  an  open  fracture  re- 
sults (see  Fig.  519).  If  the  internal  lateral  ligament  holds  against 
this  lateral  force,  the  tip  of  the  internal  malleolus  may  be  pulled 
.off. 


396 


FKACTIRES    OF    THE    LEG 


Symptoms. — The  ankle  presents  a  very  constant  appearance 
after  this  fracture.  A  traumatic  synovitis  exists.  Great  swelHng 
appears,  at  first  chiefly  upon  the  inner  side  of  the  ankle.  The 
ankle-joint  becomes  distended  with  blood  and  serum.  All  the 
natural  hollows  about  the  joint  are  obliterated.  The  foot  is 
everted,  appearing  to  have  Ix'cn  pushed  bodily  outward.  The 
internal  malleolus  is  unduly  prominent.  vSome  of  this  prominence 
is  masked  by  the  swelling.  The  bony  connections  and  natural 
support  of  the  foot  having  been  removed,  the  foot  drops  back- 


Astragalus 


Cuboid 


Fig.  526.— Fracture  of  the  tip  of  each  malleolus.     Dislocation  of  the  foot  backward.    Note  the 
prominence  in  front  of  the  ankle.     Same  case  as  figure  525  (X-ray  tracing). 


ward,  partly  because  of  the  pull  of  the  calf -muscles,  but  chiefly 
because  of  its  own  weight  (see  Figs.  520,  521).  The  deformity, 
therefore,  is  a  double  one,  a  lateral  sliding  of  the  foot  outward  and 
an  anteroposterior  dropping  of  the  foot  backward.  The  malleoli 
are  spread  apart :  the  measured  distance  between  them  is  increased 
over  the  normal.  Palpation  close  above  the  anterior  articular 
edge  of  the  tibia  and  the  astragalus  reveals  tenderness  over  the 
ruptured  tibiofibular  ligament.  The  backward  displacement  is 
best  measured  by  the  length  of  the  line  from  the  front  of  the 
ankle  to  the  cleft  between  the  first  and  second  toes.     This  line 


POTT'S    FRACTURE 


397 


will  be  found  shortened  upon  the  injured  side.  There  is  tender- 
ness over  the  fracture  of  the  fibula.  If  the  internal  malleolus  is 
fractured,  the  sharp  ridge  at  the  broken  edge  can  be  distinctly 
felt.  Grasping  the  posterior  part  of  the  foot  firmly  with  the  whole 
hand  while  the  other  hand  steadies  the  lower  leg  just  above  the 
ankle,  abnormal  lateral  mobility  of  the  foot  may  be  detected  (see 
Fig.  522).  The  foot  will  be  felt  to  move  inward  to  its  natural  posi- 
tion. The  moment  inward  pressure  is  removed  the  foot  will  be 
seen  and  felt  to  slump  outward  again. 

Figures  523-526  inclusive  illustrate  a  reversed  Pott's  deformity. 


Diaph\sis  of  fibula. 


Epiphysis.   _ 


Diaphysis  of  tibia. 

Epiphysis. 
Astraealus. 


Fig.  527. — Normal  ankle-joint,  showing  epiphyses  (anteroposterior  view). 


the  foot  having  moved  inward  instead  of  outward  as  well  as  having 
fallen  backward. 

Treatment. — The  indications  for  treatment  are  to  place  the 
parts  in  their  normal  relations,  and  to  maintain  them  so  until 
repair  is  completed,  guarding  against  both  the  lateral  and  the  pos- 
terior deformities.  If  for  any  reason,  such  as  the  presence  of  very 
great  swelling  of  the  ankle,  it  is  expedient  to  delay  reduction,  the 
leg  should  be  placed  temporarily  in  a  pillow  and  side  splints  (see 
Figs.  492,  493,  494).  An  anesthetic  should  always  be  adminis- 
tered before  the  reduction  of  this  fracture.  The  reduction  is  thus 
rendered  painless  and,  through  relaxation  of  the  muscles,  is  made 


Upper  end  of  lower  fraR- 
mciilol  libvila. 


Aslrasraliis. / 


liUcrtial  malleolus. 


Fig.   52S. — Poll's   fracture    (anteroposterior   view).      Note   sliding  of    astragalus    oulwart 
Fracture  of  internal  malleolus.    Fracture  of  fibula.    Extreme  deformity  (X-ray  tracing). 


Lower  fragment  or 

ni)uia. 


1  Fibula. 

' .  Tibia. 


Fig.  529. — Pott's  fracture.     Same  as  figure  52S  (lateral  view). 


398 


TRKATMENT    OF    POTT'S    FRACTURP: 


399 


far  easier.  The  principles  of  the  old  Dupuytrcn  splinl.  are  the  rmes 
to  be  applied  in  the  reduction  of  this  fracture  whatever  the  appara- 
tus in  which  the  leg  is  permanently  placed.     These  consist  of  the 


Fracture  of  fibula. 


Fracture  of  internal 
malleolus. 


F'a-  53°- — Pott's  fracture.     Almost  no  displacement.     Compare  with  figure  528  (Massachusetts 
General  Hospital,  828.     X-ray  tracing). 


Unusual  space. 
Internal  malleolus. 


Fig.  531. — Pott's  fracture.    Notice  sliding  of  astragalus  outward.    Fractures  of  internal  mal- 
leolus and  fibula  (Massachusetts  General  Hospital,  548.     X-ray  tracing). 


making  of  lateral  outward  pressure  upon  the  internal  malleolus, 
lateral  inward  pressure  upon  the  foot,  and  a  forward  lift  upon  the 
posterior  part  of  the  foot  or  heel.     The  practitioner  may  very 


400 


KRACTIRES    OF    THE    LEG 


properly  use  the  Diijniylren  splint.  It  is  thought  to  be  iineoni- 
t"i)rtahle,  but  it  is  ni)t  if  properh-  ai)])lie(l.  It  is  \ery  elTieient  in 
holding  the  fraeturc  reduced. 

The  Diif>uyfrr>i  Sf^l{)if. — This  is  a  Ijoard  from  one  cjuarter  to 
one-half  of  an  inch  thick,  long  enough  to  extend  from  the  middle 
of  the  thigh  to  six  inches  below  the  sole  of  the  foot,  and  as  wide  as 
the  calf  of  the  leg  from  front  to  back  (see  Fig.  535).-  At  its  lower 
or  foot  end  it  is  serrated  with  three  or  four  teeth,  as  seen  in  the 
illustration.     It  is  ])addcd  with  folded  sheets,  so  that  when  it  is 


Asliaijalu.-..    — 


—  FrricUire  nf  ri1)ul:i. 


Fig-  532. — I'otl's  fracture,  sluiwitig-fraL-Uinjof  llie  filnila  and  but  sliglil  sliiliii.t;  of  tlic  astra- 
galus, a  sufficient  distance,  however,  to  lia\e  niafle  a  rui)ture  of  llie  internal  lateral  litjanient 
highly  probable  (X-ray  tracing). 


applied  to  the  inner  surface  of  the  limb,  the  padding  extends  to 
just  ab(n-e  the  level  of  the  internal  malleolus,  the  serrated  end  of 
the  splint  projecting  six  inches  below  the  sole  of  the  foot.  The 
padding,  as  seen  in  the  illustration,  is  so  thick  at  the  lower  end  over 
the  internal  malleolus  that  suflficient  room  is  left  for  inversion  and 
rotation  of  the  foot  upon  its  anteroposterior  axis  without  its  im- 
pinging upon  the  splint  in  the  least.  The  splint  is  held  in  place  by 
straps  and  buckles :  one  is  placed  above  the  ankle,  one  above  the 
knee,  and  a  third  is  placed  at  the  upper  end  of  the  splint.  For  the 
proper  application  of  the  splint  an  assistant  is  needed.     The  splint 


TREATMENT  OF  POTT'S  FRACTURE 


401 


is  applied  while  the  leg  rests  upon  the  bed.  An  assistant  steadies 
the  splint  and  the  leg  so  that  they  both  project  clear  of  the  foot  of 
the  bed.  A  roller  bandage  is  then  applied  in  circular  turns  about 
the  ankle  and  splint  from  the  splint  toward  the  leg.  After  two 
circular  turns  are  made,  the  assistant  adducts  and  inverts  the 
ankle  and  foot,  and  this  position  is  held  by  the  third  turn  of  the 
bandage,  which  is  passed  around  the  forward  part  of  the  foot  and 
over  one  of  the  serrations  of  the  splint  (see  Fig.  536).  In  order 
to  hold  this  firmly  a  turn  is  then  taken  around  the  ankle.     A 


Fig.  533. — Splintering  of  the 
lower  end  of  fibula  (Massachu- 
setts General  Hospital,  1105. 
X-ray  tracing).- 


Seat  of 

fracture. 


Fig.  534. — Fracture  of  the  internal  malleolus  (Massa- 
chusetts General  Hospital,  1084.     X-raj'  tracing). 


figure  of  eight  is  then  applied  for  several  turns  about  the  foot  and 
ankle,  crossing  the  ankle  in  front  of  the  instep  at  each  turn.  Each 
succeeding  turn  is  ca,ught  by  the  succeeding  serration  of  the  splint. 
At  the  same  time  the  foot  is  lifted  forward  by  pressure  from  be- 
hind, and  this  forward  lift  is  maintained  by  circular  turns  of  the 
bandage.  The  whole  limb  is  placed  upon  pillows.  Thus,  the 
eversion  and  posterior  dropping  of  the  foot  are  corrected.  This 
splint  forms  a  good  temporary  or  emergency  dressing  for  Pott's 
fracture.  This  dressing  corrects  the  eversion,  but  there  is  great 
26 


402 


FRACTrRES    OF    Till'    I, KG 


danger  thai  the  fool  nia\"  slniii])  backward  unless  most  earerully 
watched.  This  faihire  to  hold  the  posterior  (lis])laeenient  cor- 
rected is  the  defect  of  the  Dupnytren  splint. 

The  Posterior  Wire  Sf^liiit  iciih  Ciirreil  I-\^o{-pieee  (see  iMgs.  537, 
538,  5,19V — The  posterior  wire  sjilint  extending  to  the  middle  of 
the  thigh  is  another  ap]:)aratiis  used  in  treating  Pott's  fracture. 


r/u 

W[ 

Hi^^^ta 

i 

^^^^^^^H 

'M 

\ 

Fig-  535- — Pott's  fracture.     Uupuylren's  splint.     Note  length  of  splint;  position  of   straps; 
arrangement  of  padding  ;  space  between  foot  and  splint. 


The  foot-piece  should  be  twisted  at  the  ankle,  so  as  to  hold  the 
foot  when  inverted  (see  Fig.  537).  The  splint  is  covered  and 
padded  in  the  usual  way.  The  patient  is  anesthetized.  The 
leg  is  placed  upon  the  splint.  The  foot  is  strongly  inverted  by 
great  lateral  pressure  put  upon  the  posterior  part  of  the  foot.  This 
inversion  of  the  foot  can  not  be  made  too  strongly,  for  the  deform- 


tre;atment  of  pott's  fracture; 


403 


ity  can  not  be  overcorrected.  The  position  of  extreme  inversion 
is  not  a  painful  one  to  maintain.  Ordinarily,  the  lateral  pressure 
applied  is  too  slight  entirely  to  correct  the  deformity.  The  foot  is 
held  to  the  inverted  foot-piece  by  straps  of  adhesive  plaster,  pads, 
and  side  sphnts  (see  Fig.  538).     A  pad  is  applied  to  the  sole  of  the 


Fig.  536. — Pott's  fracture.  Dupuytren's  splint. 
Note  serrations  of  splint  and  turns  of  bandage 
adducting  foot. 


Fig.  537. — Cabot  posterior  wire 
splint  bent  at  the  ankle  for  a  Pott's 
fracture  of  the  right  leg.  To  be  used 
to  assist  in  maintaining  adduction  of 
the  foot. 


foot,  and  so  placed  as  to  maintain  the  long  anteroposterior  arch 
of  the  foot.  It  is  found  that  if  this  is  not  done,  there  is  consider- 
able flattening  of  this  arch  upon  recovery.  The  forward  lift  upon 
the  foot  is  made  and  maintained  by  proper  padding  posteriorly  to 
the  lower  leg  and  just  above  the  heel  (see  Fig.  537).     The  lift  may 


404 


FRACTURKS   OK    THE    LEG 


be  reinforced  by  smoothly  applied  strips  of  adhesi\e  ])laster  ])laced 
laterally  on  the  fool  and  carried  under  the  heel  and  u])  and  over 
the  end  of  the  foot-piece.  These  adhesive-plaster  strips  serve  as  a 
sling  for  the  foot.  There  is  one  other  way  to  avoid  pressure  upon 
the  point  of  the  heel,  and  that  is  by  placing  beneath  the  heel  a  ring 
of  sheet  wadding  covered  with  a  tightly 
wound  bandage  (see  Fig.  506).  These 
methods  of  protecting  the  heel  from  press- 
ure may  all  be  used  at  one  time  to  advan- 
tage. The  side  splints  are  applied  with 
great  care,  being  so  padded  as  to  maintain 
the  outward  pressure  upon  the  inner  surface 
of  the  lower  end  of  the  tibia,  and  the  inward 
pressure  upon  the  outer  surface  of  the  foot. 
Very  great  care  must  be  exercised  that  there 
is  no  recurrence  of  the  deformity.  Frequent 
readjustments  are  necessary. 

The  Lateral  and  Posterior  Plaster-of-Paris 
Splints  (Stimson's  Splint). — The  posterior 
splint  (see  Fig.  539)  extends  from  the  toes 
along  the  sole  of  the  foot  around  the  back 
of  the  heel  and  up  the  back  of  the  leg  to 
the  knee  or  to  the  middle  of  the  thigh.  The 
lateral  splint  (see  Fig.  540)  begins  at  the  ex- 
ternal malleolus,  passes  over  the  dorsum  of 
the  foot  to  the  inner  side  under  the  sole,  and 
upward  along  the  outer  side  of  the  leg  to  the 
same  height  as  the  posterior  splint.  Each  of 
these  splints  is  made  of  about  six  or  eight 
strips  of  washed  crinoline,  four  inches  wide 
and  long  enough  to  extend  from  around  the 
foot  to  the  bend  of  the  knee  or  middle  of  the 
thigh.  The  leg  is  protected  bv  roller  bandages  of  sheet  wadding. 
Plaster  cream  is  rubbed  into  the  crinoline  strips  one  after  the  other 
until  all  the  strips  have  been  used.  The  posterior  splint  is  applied 
first,  and  held  snugly  by  a  gauze  bandage  to  the  leg  and  foot. 
Then  the  remaining  crinoline  strips  are  likewise  covered  with 
plaster  cream    and  applied  as  the  lateral    splint   (see  Fig.   541). 


Fig.  538. — Pott's  frac- 
ture. Cabot  posterior  wire 
splint  and  side  splints. 
Note  position  of  lateral 
pads  and  twisted  foot- 
piece.  Side  splints  are 
shown  unpadded  (dia- 
gram). 


TREATMENT  OF  POTT'S  FRACTURE  405 

This  is  also  held  snugly  by  a  gauze  bandage  to  the  leg  and  foot. 
During  the  application  of  the  splint  and  until  the  plaster-of- Paris 
has  set,  the  foot  should  be  held  in  a  corrected  position  by  an  as- 
sistant. These  two  plaster-of- Paris  splints  are  preferable  to  the 
encircling  plaster  splint,  the  ordinary  "plaster  leg,"  for  by  their 
use  the  ankle  can  be  inspected.  Less  judgment  is  requisite  in  its 
application  to  insure  the  correction  of  the  deformity  than  by  the 


Fig-  539- — Pott's  fracture.     Stitnsoii's  splint.     Posterior  plaster  (represented  two  inches  too 
long  at  the  upper  end). 


use  of  the  ordinary  "plaster  splint."  As  the  swelling  subsides 
and  the  plaster  becomes  loose,  if  the  splints  are  kept  tight  by 
bandaging,  the  deformity  can  not  possibly  recur. 

Care  of  the  Fracture  after  the  Permanent  Dressing  is  Applied. — 
If  the  posterior  and  side  splints  are  used :  After  the  initial  swelling 
has  subsided — i.  e. ,  after  the  first  week — the  leg  may  be  placed  in  a 
plaster-of- Paris  splint  (circular  bandage),  and  the  patient  allowed 


4o6 


FRACTliRES    OF    THE    LEO 


up  and  about  with  crutches.  The  plaster  should  be  split  after 
application  and  held  in  place  by  straps  or  a  bandage.  If  the 
Stimson  splint  is  used,  the  patient  may  be  allowed  up  and  about 
with  crutches  at  the  end  of  the  first  week. 

Massage  mav  be  applied  to  the  exposed  parts  of  the  leg  and  foot 
daily.     At  the  third  week  all  dressings  should  be  removed,  and 


L 

w 

1 

1 

\ 

L^ 

" 

'jj^  J 

Fig.  540. — Pott's  fracture.     Slimsoii's  splint  completed.     Lateral  plaster  and  posterior  plaster. 


gentle  massage  applied  to  the  whole  leg  from  toes  to  groin,  especial 
attention  being  paid  to  the  region  of  the  ankle.  Massage  and 
gentle  passive  motion  in  an  anteroposterior  direction  only  should 
be  applied  at  least  once  or  twice  daily  after  the  second  week.  All 
lateral  motion  is  to  be  avoided.  After  the  fifth  or  sixth  week  a 
flannel  bandage  will  be  all  the  support  needed,  although  comfort 


PROGNOSIS    AND    RESUI^TS  407 

may  demand  a  thin,  stiff,  retentive  splint  at  times.  At  the  end 
of  two  months  some  weight  may  be  borne  upon  the  foot. 

Of  the  three  methods  of  dressing  a  Pott's  fracture  the  posterior 
and  lateral  plaster  splint  of  vStimson  is  by  far  the  simplest  and  it  is 
efficient  in  every  way.  Moreover,  it  allows  of  massage  being  in- 
stituted early  with  the  least  disturbance  to  the  ankle.  The  pos- 
terior wire  splint  is  more  difficult  of  application,  and  needs  careful 
watching  and  frequent  readjustment.  With  the  posterior  wire 
splint  in  use  the  foot  or  leg  is  easily  accessible  to  early  massage  by 
simply  loosening  the  side  splints. 

Prognosis  and  Results. — In  young  adults  there  should  be  no 


Fig.  541. — Pott's  fracture.     Stimson's  splint  removed.     Lateral  and  posterior  plasters. 

deformity  and  almost  no  permanent  disability.  In  adults  there 
will  be  some  stiffness  for  a  time.  If  the  lateral  deformity  has  not 
been  completely  corrected,  a  traumatic  pronation  of  the  foot  will 
result.  The  longitudinal  arch  of  the  foot  should  be  supported 
always  by  a  suitable  pad  under  the  instep  for  at  least  six  months 
following  this  fracture,  whether  there  is  deformity  or  not.  If 
there  is  deformity,  it  will  relieve  the  pain.  An  insole  of  leather 
with  a  pad  stitched  to  it  for  support  to  the  arch  of  the  foot  is  often 
of  great  service.  If  there  is  no  pain  or  deformity,  it  will  strengthen 
the  foot  until  walking  is  easy  again,  and  will  prevent  deformity 
appearing.  If  the  anteroposterior  deformity  has  not  been  cor- 
rected, pain  may  be  experienced  upon  using  the  foot.     The  foot  is 


408  FRACTURES    OF    THE    LEG 

shortened  and  dorsal  llcxion  is  much  liindered,  so  that  the  gait  is 
decidedly  impaired.  The  ])atie!il  will  walk  with  a  more  or  less 
stiff  ankle.  In  those  cases  in  which  there  is  great  deformity 
associated  with  extensiye  laceration  of  the  soft  parts,  the  foot  and 
ankle  may  for  many  weeks  subsequent  to  imion  be  painful,  stiff, 
and  swollen.  Pain,  stifTness,  and  swelling  increase  with  the  age 
of  the  patient — i.  c.  the  younger  the  patient,  the  less  discom- 
fort will  there  be  following  this  fracture. 

The  Operative  Treatment  of  Old  Pott's  Fractures. — The  in- 
dications for  operation  will  be  persisting  lateral  or  backward  dis- 
placements. The  only  method  for  the  relief  of  these  deformities 
is  by  osteotomy  of  the  tibia  and  fibula.  The  results  following 
this  operation  are  satisfactory. 

Open  Pott's  Fracture  (see  Fig.  519). — The  ankle-joint  is  in- 
yolyed.  Two  things  are  to  be  considered  in  deciding  upon  the 
treatment  of  the  injury — the  extent  of  the  laceration  of  the  soft 
parts  and  the  amount  of  injury  to  the  bones.  If  the  laceration  is 
so  great  that  the  foot  is  useless,  amputation  is  indicated.  Am- 
putation is  indicated  in  only  two  other  instances — old  age  and 
sepsis.  If  the  laceration  is  not  great,  and  any  existing  disloca- 
tion can  be  reduced,  it  should  be  reduced  without  excision,  proper 
drainage  being  proyided,  both  anteriorly  and  posteriorly,  to  the 
joint.  If  the  laceration  is  not  great  and  reduction  of  the  deform- 
ity is  impossible,  then  either  partial  or  complete  excision  should 
be  done.  If  there  is  great  injury  to  bone,  whether  the  disloca- 
tion can  or  can  not  be  reduced,  a  partial  or  complete  excision 
should  be  done.  In  eyery  open  Pott's  fracture,  no  matter  how 
small  the  wound  of  the  soft  parts,  in  order  to  insure  an  aseptic 
wound  it  should  be  enlarged  sufficiently  for  thorough  cleansing 
with  antiseptic  solutions  in  eyery  part.  Extreme  conseryatism 
should  characterize  the  treatment  of  recent  open  Pott's  fracture. 
In  the  large  majority  of  cases  treated  upon  the  conservative  or 
expectant  plan  a  useful  ankle-joint  and  foot  will  result.  The 
older  the  adult  patient  is,  the  more  radical  must  be  the  treatment. 


CHAPTER  XV 

FRACTURES  OF  THE  BONES  OF  THE  FOOT 

Fracture  of  the  astragalus  is  caused  by  a  blow  on  the  sole  of 
the  foot,  as  in  a  fall  from  a  height  (see  Fig.  542).  Fracture  of  the 
OS  calcis  is  often  present  in  the  same  foot  with  fracture  of  the 
astragalus.  The  ankle-joint  may  or  may  not  be  involved.  The 
diagnosis  is  difficult  without  the  use  of  the  Rontgen  ray.  Crepitus 
may  be  elicited.  Great  swelling  may  appear  in  the  region  of  the 
fracture. 


Tibia. 


Line  of  fracture. 


Head  and  neck  ^-y 

of  astragalus.  /    \ 

Cuneiform.     Scaphoid.    \  /  \ 


Body  of  astrag- 
alus. 


~  Os  calcis. 


—  Cuboid. 


Fig.  542. — Fracture  of  the  neck  of  the  astragalus  (X-ray  tracing). 


It  is  highly  probable  that  many  cases  of  sprained  ankle  have 
been  cases  of  fracture  of  the  astragalus.  If  there  is  no  displace- 
ment, treatment  will  consist  in  immobilizing  the  ankle-joint  with 
the  foot  held  at  a  right  angle  with  the  leg.  As  soon  as  the  swelling 
has  begun  to  subside,  massage  may  be  used  to  advantage  and  con- 
valescence be  thus  hastened.  The  most  satisfactory  dressing  is  a 
plaster-of- Paris  splint  extending  from  the  toes  to  below  the  knee, 
applied  and  immediately  split  open,  so  as  to  form  a  removable 
splint.     This  may  be  taken  off  for  massage  and  passive  motion. 

409 


Fig-  543- — Dorsal  view  of  bones  of  the  foot.     Tarsus,  metatarsus,  and  phalanges. 


Fig.  544. — Lateral  view  of  foot  showing  longitudinal  arch  of  foot.     Note  relation  of  indi- 
vidual bones  on  inner  side  of  foot. 


410 


Fracture;  of  the  os  calcis 


411 


Recovery  takes  place  with  fair  movement  at  the  ankle-joint,  so 
that  after  from  two  months  and  a  half  to  three  months  the  patient 
can  walk  without  support.  After  this  time  complete  recovery  is 
slow.  More  or  less  stiffness  and  pain  may  exist  for  four  or  six 
months  after  the  accident. 

Fracture  of  the  Os  Calcis. — The  os  calcis  is  fractured  by  a 
fall  on  the  sole  of  the  foot,  as  well  as  by  a  powerful  contraction  of 


Fig.  545. — An  X-ray  of  the  bones  of  the  normal  adult  ankle  and  part  of  tarsus.     Lateral 

view. 


the  gastrocnemius  muscle  and  strong  tension  upon  the  tendo 
Achillis.  It  may  be  crushed,  fractured  transversely  or  longi- 
tudinally, or  a  piece  may  be  torn  off  from  its  posterior  portion 
near  the  insertion  of  the  tendo  Achillis  (see  Figs.  546,  547). 
The  symptoms  of  fracture  will  be  the  usual  ones  of  crepitus, 
swelling,  pain,  abnormal  mobility.  The  heel  is  seen,  by  com- 
parison with  its  uninjured  fellow,  to  be  enlarged.  This  fracture 
is  sometimes  associated  with  fracture  of  the  astragalus  (see  Fig. 


412 


FRACTURES  OF  THE  BONES  OF  THE  FOOT 


552).  The  treatment  is  to  immobilize  the  foot  at  the  angle  that 
will  best  hold  the  fragment  approximately  in  apposition.  Com- 
plete plantar  flexion  of  the  foot  may  be  needed  to  bring  the  frag- 


ExtcTiial  malleolus 


Posterior  fragmenl  ^  / 

of  OS  calcis.  / 

Inferior  fragment  \  / 

of  OS  calcis.  \ 


\  u^     Anterior  fragment 
)l  of  OS  calcis. 


Fig.  546.— Fracture  of  the  os  calcis  in  the  body  of  the  bone  (X-ray  tracing). 


Fig.  547.— Fracture  of  the  os  calcis,  almost   transversely  across  the  junction  of  the  body  and 

neck  (X-ray  tracing). 


ments  well  into  position.  The  pull  upon  the  tendo  Achillis  is  in 
this  position  removed  from  the  posterior  fragment.  Massage 
should  be  instituted  early — during  the  first  week.  The  remov- 
able plaster-of- Paris  dressing  is  the  best  form  of  splint.     After 


FRACTURE  OF  OS  CALCIS — TREATMENT 


413 


three  weeks  the  splint  should  be  removed,   and  a  close  fitting 
flannel  bandage  applied,  with  small  pads  under  the  malleoli  and 


\ '  Os  calcis. 

—  -p^     Nv\ '  '-'^  calcis. 

T      ^^ 


Fig.  548. — Fracture  of  the  left  os  calcis  through  the  bodj'  of  the  bone  (X-ray  tracing.) 


_4 Astragalus. 


—  Line  of  fracture. 


Fig.  549. — Fracture  of  the  os  calcis.     The  part  torn  off  is  that  to  which  is  attached  the  tendo 
Achillis.     Notice  displacement  (Massachusetts  General  Hospital,  1652.     X-ray  tracing). 


on  each  side  of  the  tendo  Achillis.     The  pads,  if  applied  with 
considerable  pressure,  will  assist  very  materially  in  reducing  the 


414 


FRACTURES   OF   THE    BONES   OF  THE   FOOT 


swelling  and  in  rcstorinf^  form  to  the  ankk'.     It   will  be  about 
two  months  before  the  patient  should  bear  mueh  weight  upon  the 


Body  of  astragalus. 1 


Neck  of  astragalus.  ^J— 
t 
/ 


-\— External  malleolus. 

\ 

-\ —  Os  calcis. 

—  I —  Os  calcis,  posterior 
I  fragment. 

/ 

■  7 Os  calcis.  anterior 

y  fragment. 


Fig.  550. — Fracture  of  the  right  os  calcis. 


Upper  border  of  os 
calcis. 


Os  calcis.  .^4 


Fig.  551.— Fracture  of  the  os  calcis  without  great  displacement  (Massachusetts  General 
Hospital,  102.     X-ray  tracing). 


foot.     After  three  to  four  months  walking  will  be  comparatively 
easy.     It  is  often  the  case  after  fracture  of  the  os  calcis  and  also 


FRACTURE  OF  the;  METATARSUS 


415 


after  fracture  of  the  astragalus  that  there  is  considerable  disturb- 
ance of  the  normal  mechanism  of  the  foot.  A  traumatic  flat-foot 
results  from  the  accident.  This  can  be  greatly  relieved  by  the 
introduction  into  the  shoe  of  a  leather  pad,  to  raise  the  instep  and 
take  the  strain  off  the  injured  part.  The  patient  may  find  that 
for  a  period  of  six  months  or  more  the  wearing  of  this  pad  is  a 
great  support  and  comfort.  The  hot-air  baking  is  very  satis- 
factory for  the  relief  of  the  pain  and  stiffness  felt  throughout  the 
ankle  and  foot.  The  hot-air  treatment,  combined  with  massage, 
helps  to  hasten  convalescence.  This  treatment  should  be  used 
once  daily  until  the  pain  in  the  foot  has  disappeared. 

Open  fracture  of  the  astragalus  and  os  calcis^  if  treated  anti- 


^ '§■-  552- — Case  :  Posterior  view  of  fracture  of  right  os  calcis  and  of  left  astragalus.  Deformity. 
Note  fullness  each  side  of  the  tendo  Achillis  (see  X-ray  tracings  542  and  550). 


septically,  recovers  with  a  useful  ankle  and  foot  even  though  the 
ankle-joint  is  ankylosed.  The  mediotarsal  joint  becomes  more 
flexible  than  it  ordinarily  is.  The  loss  of  motion  at  the  ankle- 
joint  is  compensated  for  by  the  mediotarsal  joint  motion,  and  the 
individual  may  walk  with  hardly  a  perceptible  limp.  Removal 
by  operation  of  the  fractured  bone  is  attended  by  good  functional 
results,  and  if  the  bone  is  much  comminuted  or  dislocated,  opera- 
tion is  indicated. 

Fracture  of  the  Metatarsal  Bones. — This  fracture  is  caused 
by  direct  violence.  There  is  evidence  to  show  that  indirect  vio- 
lence may  cause  a  fracture  of  metatarsal  bones.  The  first  and 
fifth  bones  are  the  ones  most  often  broken  (see  Fig.  553).     The 


4i6 


FRACTURES  OF  THE  BONES  OF  THE  FOOT 


svmpttnns  are  swelling,  pain,  crepitus,  and  abnormal  mobility. 
The  weight  can  not  ijc  borne  upon  the  foot  without  pain.  There 
is  never  great  displacement.  In  order  to  avoid  trouble  in  walking 
after  union  has  occurred,  it  is  wise  to  make  the  approximation  of 
the  fragments  as  nearly  accurate  as  possible.     A  closed  or  simple 


Seat  of  fracture. 


Sesamoid  bones. 


Fig.  553.— Fracture  across  the  first  metatarsal  of  the  right  foot  (X-ray  tracing). 


Fig.  554.— Fracture  of  the  first  phalanx  of  the  little  toe  (Massachusetts  General  Hospital,  115. 

X-ray  tracing). 


fracture  is  ordinarily  uncomplicated.  Union  takes  place  in  from 
three  to  four  weeks.  It  will  be  at  least  from  two  to  four  months 
before  the  foot  can  be  used  without  thought  of  the  injury  received. 
If  the  fracture  is  open,  repair  will  be  slower  than  after  a  closed 
fracture.     If  the  wound  is  kept  clean  and  free  from  infection,  no 


fracture;  of  the;  phalanges  of  the  foot  417 

complications  will  arise.  If,  on  the  other  hand,  the  wound  be- 
comes infected,  necrosis  of  bone,  abscess  formation,  burrowing  of 
pus,  and  great  swelling  of  the  foot  may  occur,  all  of  which  will 
greatly  delay  the  healing  process.  The  foot  should  be  immobilized 
by  a  lateral  molded  splint  of  plaster-of- Paris.  This  should  be 
placed  upon  either  the  outer  or  inner  side  of  the  ankle,  according 
as  the  outer  or  inner  metatarsals  are  broken.  The  splint  should 
extend  from  the  middle  of  the  calf  of  the  leg  to  the  tips  of  the  toes. 
It  is  held  in  position  by  a  roller  bandage  of  gauze. 

Fracture  of  the  Phalanges  of  the  Foot. — These  fractures  are 
rather  unusual,  except  from  a  crush  of  the  foot  (see  Fig.  554). 
They  are  sometimes  open.  The  same  general  rules  of  treatment 
apply  to  fractures  of  these  bones  as  to  fractures  of  the  phalanges 
of  the  hand.  A  simple  plantar  splint  of  splint  wood,  padding  of 
the  toes,  and  adhesive-plaster  straps  will  be  sufficient  to  hold  the 
fracture.  If  the  plantar  splint  covers  the  entire  sole  of  the  foot,  it 
will  prove  of  great  comfort.  It  is  sometimes  wise  to  immobilize 
the  ankle-joint  by  the  thin  plaster  side  splint,  particularly  if  there 
is  swelling  of  the  leg  and  ankle. 


27 


CHAPTER  XVI 
ANATOMICAL  FACTS  REGARDING  THE  EPIPHYSES 

Hitherto  our  knowledge  of  injuries  to  the  epiphyses  has  been 
obtained  mainly  through  clinical  and  pathological  observation. 
This  knowledge  is  only  approximately  correct.  With  the  assist- 
ance of  the  Rontgen  ray  a  yery  great  advance  is  being  made  in  the 
accuracy  of  our  knowledge  of  the  epiphyses.  Whereas  there  will, 
perhaps,  always  exist  differences  in  the  times  of  the  appearance  of 
the  ossification  centers  and  the  times  of  union  of  the  epiphyses,  the 
discrepancies  in  each  observer's  series  of  cases  will  grow  less  and 
less. 

The  importance  of  an  exact  knowledge  of  the  epiphyses  to  those 
having  to  do  with  injuries  in  the  neighborhood  of  joints  is  un- 
doubted. The  diagnosis,  prognosis,  and  treatment  of  joint  in- 
juries and  injuries  in  the  immediate  vicinity  of  joints  is  far  more 
satisfactory  than  ever  before.  The  book  by  John  Poland  upon 
"Traumatic  Separation  of  the  Epiphyses,"  from  which  the  follow- 
ing data  are  largely  taken,  marks  an  era  in  this  branch  of  surgery. 
Only  those  facts  that  are  considered  especially  important  for 
practical  everyday  use  are  here  mentioned. 

THE   DATE   OF   THE   APPEARANCE   OF   OSSIFICATION  IN  THE 
CHIEF  EPIPHYSES  OF  THE  LONG  BONES 

[A/le)   Poland) 

,  ^  ,  •  .,  f  Lower  end  of  femur. 

At  birth •'     ,  1     r  .1  • 

(  upper  end  ol  tibia. 

.  ^  f  Upper  end  of  femur. 

At  one  vear <  tt  i     r  i, 

l  Upi^er  end  oi  humerus. 

■  ^  1  1    If  f  Lower  end  of  tibia. 

At  one  and  one-hall  years ■    ,  i     r  i 

t  l^ower  end  ot  humerus. 

,  ^  ,  r  Lower  end  of  radius. 

At  two  years <  ^  i     r  cu  i 

•'  (^  Lower  end  of  hbula. 


Great  trochanter  of  femur. 
Great  tuberositv  of  humerus. 


At  three  years X 

,  ^  r  (  Upper  end  of  uhia. 

At  tour  years \  ■,-  i     r  cu    i 

■'  \  Up[)er  end  of  hbula. 

From  five  to  six  years I  Upper  end  of  radius. 

.       .  •■  f  Lower  end  of  ulna. 

^      ^  \  Lesser  trochanter  of  femur. 

418 


THE   UPPER    EPIPHYSIS    OF    THE    HUMERUS  419 

After  a  most  exhaustive  study  of  pathological  and  clinical 
material,  both  of  his  own  and  that  of  other  observers,  Poland 
concludes  that  the  order  of  frequency  of  separation  of  the  epiph- 
yses is  about  as  follows : 

1.  The  upper  epiphysis  of  the  humerus. 

2.  The  lower  epiphysis  of  the  femur. 

3.  The  lower  epiphysis  of  the  radius. 

4.  The  lower  epiphysis  of  the  humerus. 

5.  The  lower  epiphysis  of  the  tibia. 

6.  The  upper  epiphysis  of  the  tibia. 

Greater  force  is  necessary  to  cause  a  separation  of  an  epiphysis 
than  is  required  to  cause  a  fracture  of  the  same  bone.  In  child- 
hood severe ,  traumatism  to  a  joint  will  less  frequently  produce 
a  luxation  of  that  joint  than  a  separation  of  the  epiphysis.  The 
periosteum  remains  attached  to  the  epiphysis  and  is  easily  stripped 
from  the  diaphysis. 

Pain  is  less  in  epiphyseal  separation  than  in  fractures.  This  is 
especially  noticeable  in  separation  of  the  upper  epiphysis  of  the 
humerus.  Pressure  even  very  lightly  over  a  fracture  of  the  upper 
end  of  the  humerus  produces  pretty  severe  pain,  whereas  pressure 
over  a  separated  upper  humeral  epiphysis  does  not  evince  much 
pain.  This  peculiarity  is  in  evidence  in  injuries  to  the  lower  end 
of  the  radius  as  well. 

The  upper  epiphysis  of  the  humerus  is  composed  of  three 
separate  centers  of  ossification:  That  for  the  head,  appearing  at 
two  years ;  that  for  the  great  tuberosity,  appearing  at  three  years ; 
that  for  the  lesser  tuberosity,  appearing  at  four  years.  These 
three  centers  coalesce  to  form  the  upper  epiphysis,  and  it  unites, 
at  from  the  twentieth  to  the  twenty-fourth  year,  to  the  diaphysis 
of  the  humerus.  The  upper  humeral  epiphysis  therefore  includes 
the  two  tuberosities,  the  whole  of  the  head,  and  the  anatomical 
neck.  The  cone-shaped  end  of  the  diaphysis  appears  more  dis- 
tinctly as  age  advances.  In  infancy  the  upper  end  of  the  diaph- 
ysis is  almost  flat  across. 

Separation  of  the  upper  humeral  epiphysis  will  not  necessarily, 
except  in  cases  of  very  great  violence,  open  the  shoulder-joint,  for 
the  capsule  is  firmly  attached  to  the  epiphysis  and  the  synovial 
membrane  is  loosely  attached  to  the  diaphysis.     The  epiphyseal 


Fig.  555. — Epiphyses  of  the  scapula  at  five  years  as  shown  by  X-ray.     (X-ray  by  Mr.  Dodrl.) 


\ 


F'K-  556. — Epiphyses  of  scapula  at  fourteen  years  as  shown  by  the  X-ray.     (X-ray  by 

Mr.  Dodd.) 
420 


F'g-  557-— Epiphysis  of 
the  upper  end  of  humerus  at 
five  years.  Note  shape  of 
epiphysis.  (X-ray  by  Mr. 
Dodd.) 


Fig.  558. — Epiphysis  of  the 
upper  end  of  the  humerus  at 
seven  years.  (X-ray  by  Mr. 
Dodd.) 


Fig.  559. — Upper  end  of 
humerus  at  eighteenth  year. 
Epipliysis  detached  to  show 
pyramidal  end  of  diaphysis 
with  its  upward  projecting 
apex  (after  Poland). 


/Mm-'''' 


/. 


,;^>^^^v- 


Fig.  560. — Section  of  upper  end  of  hu- 
merus at  seventeenth  year.  Note  cancel- 
lous structure  and  shape  of  diaphyseal  end 
(after  Poland). 


Fig.  561. — Frontal  section  of  lower  end 
of  humerus  at  the  age  of  six  and  a  half 
years.  Anterior  half  of  section.  Centers 
of  capitellum  and  internal  epicondyle  well 
developed.     Actual  size  (after  Poland). 


421 


Fig.  562. — Deiachiiieiit  of  the  epiph- 
yses of  the  external  epicoiid\le  and  of 
Ihecapitellum.  Age  fifteen  years  (after 
Poland). 


Capilcllum. 


Fig.  563. — Drawing  of  separated  lower  humeral 
epiphysis  before  puberty.  The  articular  end  is 
largely  cartilage  (after  Poland). 


P'ig.  564. — Sagittal  section  of  elbow-joint.  Hu- 
mero-ulnar  articulation  at  fifteen  and  une-lialf 
years.  Note  relation  of  the  synovial  membrane 
to  the  epiphyseal  lines  (after  Poland). 


Fig.  565.  —  Sagittal  section 
through  the  outer  portion  of  the 
elbow-joint.  Note  relation  of  the 
synovial  membrane  to  the  epiph- 
yseal lines  f)f  the  bones.  Radiohu- 
meral  articulation  at  fifteen  and 
one-half  years  (after  Poland). 


422 


Fig.  566. — Radius  and    ulnar  epiphyses  at 
five  years.     (X-ray  by  Mr.  Dodd.) 


Fig.  567. — Radius  and  ulnar  epiphyses  at 
seven  years.     (X-ray  by  Mr.  Dodd.) 


Fig.  568.— Frontal  section  through  the  bones  of  the  wrist  and  hand  at  eighteen  years.     Note 
the  relations  of  the  synovial  membranes  to  the  lines  of  the  epiphyses  (after  Poland). 

423 


X  a 


424 


Fig.  571.  —  Epiphyses  of 
upper  end  of  the  femur  at  five 
years.     (X-ray  by  Mr.  Dodd.) 


Fig-.  572. — Frontal  section  of  left  hip-joint  in  a  boy  seventeen 
and  one-half  years  old.  Note  relation  of  synovial  membrane  to 
the  epiphyseal  lines  (after  Poland). 


Fig-  573-  —  Epiphyses  of  the 
upper  end  of  the  femur  at  seven 
years.     (X-ray  by  Mr.  Dodd.) 


F'g-  574- — Epiphyses  of  the  upper  end  of  the  femur 
at  fourteen  years.     (X-ray  by  Mr.  Dodd.) 

425 


Fig.   575. — Lower   epiphysis  of    femur.      Upper   epiphysis   of  tibia  and  fibula  at  five  years. 
(X-ray  by  Mr.  Dodd  and  Dr.  Osgood.) 


Fig.  576. — Lower  epiphysis  of  the  young  adult  femur.     (X-ray  by  Mr.  Uodd.) 

426 


Fig.  577. — Lower  epiphysis  of  the  femur  at  fif- 
teen years.     (X-ray  by  Mr.  Dodd.) 


Fig.  578. — Upper  epiphysis  of  tibia  at  five 
years.     (X-ray  by  Mr.  Dodd.) 


Fig.  579. — Upper  epiphysis  of  tibia  at  seven 
years.     (X-ray  by  Mr.  Dodd.) 


Fig.  580. — Upper  epiphysis  of  tibia  at  fourteen 
years.     (X-ray  by  Mr.  Dodd.) 
427 


Fig-.  SSi. — Epipliysis  of  the  lower  end 
of  tibia  at  seven  years.  (X-ray  by  Mr. 
Dodd.) 


Fig.  5S2. — Epiphysis  of  tlie  lower  end 
of  the  tibia  at  fourteen  years.  (X-ray  by 
Mr.  Dodd.) 


Fig.  5S3.— PIpiphyses  of  the  normal  lower  end  Fig.     5S4.  —  Epiphysis    (lower)    of 

of   tibia  and  fibula.     Child   aged  five.      (X-ray  by        fibula  at    fourteen   years.       (X-ray   by 
Mr.  Dodd.)  Mr.  Dodd.) 


428 


LOWER    EPIPHYSIS    OF    THE    RADIUS 


429 


line  is  intra-articular  upon  the  inner  side  only.  In  the  adult 
the  epiphyseal  line  marks  the  upper  limit  of  the  surgical  neck. 
The  growth  in  the  length  of  the  shaft  of  the  humerus  occurs  from 
the  upper  humeral  epiphysis.  Conical  stump  cases  following  am- 
putation of  the  upper  arm  illustrate  how  active 
the  upper  epiphysis  is  in  the  growth  in  length 
of  the  humerus. 

The  lower  epiphysis  of  the  femur,  the  largest 
epiphysis  in  the  body,  appears  before  birth,  at- 
tains a  good  size  by  two  years,  and  unites  to 
the  diaphysis  at  from  the  twentieth  to  the 
twenty-third  year. 

The  adductor  tubercle  is  on  the  diaphysis 
marking  the  level  of  the  line  of  the  epiphysis 
upon  the  inner  side  of  the  femur.  The  two 
heads  of  the  gastrocnemius  muscle  are  attached 
to  both  the  epiphysis  and  the  diaphysis,  but 
chiefly  to  the  diaphysis.  The  plantaris  is  at- 
tached to  the  diaphysis.  Both  of  these  mus- 
cles, in  a  separation  of  the  epiphysis,  are 
stripped  from  the  shaft  with  the  periosteum, 
and  act  solely  on  the  detached  epiphysis,  caus- 
ing it  to  rotate  upon  its  transverse  axis.  In 
separations  without  much  displacement  the 
knee-joint  is  not  opened.  The  quadriceps 
bursa  may  escape  injury. 

The  lower  epiphysis  of  the  radius  appears 
about  the  second  year,  and  unites  to  the  shaft 
at  from  the  nineteenth  to  the  twentieth  year. 

The  synovial  membrane  of  the  wrist-joint 
does  not  touch  the  epiphyseal  line  of  the 
radius  either  anteriorly  or  posteriorly.  It  takes  its  origin  from 
the  lower  articular  margin  of  the  epiphysis.  The  synovial  mem- 
brane of  the  inferior  radio-ulnar  articulation  extends  above  the 
epiphA^seal  lines  of  both  the  radius  and  ulna.  It  is  loosely  con- 
nected with  the  diaphysis  of  each  bone.  In  epiphyseal  separa- 
tions laceration  of  the  synovial  pouch  is  possible,  but  is  not 
absolutely  inevitable. 


Fig.  585.— Epiphy- 
ses of  fibula  at  five 
years.  (X-ray  by  Mr. 
Dodd.) 


430  ANATOMICAL    FACTS    REGARDING    THE    EPIPHYSES 

The  lower  epiphysis  of  the  humerus  is  formed  from  three 
separate  centers  of  ossification — viz.,  the  capitellum,  which  ap- 
pears at  three  years ;  the  trochlea,  which  appears  at  eleven  years ; 
the  external  epicondyle,  which  appears  at  thirteen  years.  These 
three  centers  coalesce  at  about  the  fifteenth  year,  to  form  the 
lower  humeral  epiphysis.  The  epiphysis  unites  to  the  diaphysis 
at  about  the  seventeenth  year.  The  epiphysis  for  the  internal 
epicondvle  forms  no  part  of  the  lower  humeral  epiphysis.  It 
appears  at  about  the  fifth  year,  and  joins  the  diaphysis  at  from 
the  eighteenth  to  the  twentieth  year. 

The  svnovial  membrane  at  about  the  fifteenth  year  and  after- 
ward overlaps  the  epiphyseal  line.  The  epiphyseal  line  is  a  little 
higher  on  the  outer  side  than  on  the  inner.  It  inclines  obliquely 
downward  and  inward.  The  epiphysis  is  thinner  internally  than 
externally. 

The  epiphysis  of  the  lower  end  of  the  tibia  appears  about  the 
second  vear,  and  unites  to  the  diaphysis  about  the  eighteenth 
or  nineteenth  year.  Neither  anteriorly  nor  posteriorly  does  the 
svnovial  membrane  come  in  contact  with  the  epiphyseal  line,  so 
that,  unless  great  violence  is  exercised  or  the  epiphysis  is  frac- 
tured, the  ankle-joint  is  unopened  in  separation  of  this  epiphysis. 

The  epiphysis  of  the  upper  end  of  the  tibia  appears  at  about 
the  first  year,  and  unites  to  the  shaft  at  the  twentieth  or  twenty- 
second  vear.  The  synovial  membrane  is  quite  a  little  distance 
from  the  line  of  the  epiphysis.  The  epiphyseal  line  runs  quite 
close  to  the  superior  tibiofibular  articulation. 

The  acromion  process  of  the  scapula  presents  an  epiphysis 
that  appears  at  from  the  fourteenth  to  the  sixteenth  year,  and 
unites  at  from  the  twenty-second  to  the  twenty-fifth  year.  The 
epiphysis  includes  the  oval  articular  facet  for  the  clavicle.  The 
coracohumeral  and  acromioclavicular  ligaments  are  attached  to 
it.  The  epiphysis  joins  the  acromion  behind  the  acromiocla- 
vicular joint. 


CHAPTER  XVII 
GUNSHOT  FRACTURES  OF  BONE 

The  civil  surgeon  rarely  has  opportunity  to  study  the  effect 
upon  bone  of  bullet  wounds.  He  may  see  in  his  practice  a  few 
gunshot  fractures.  His  experience  is  necessarily  limited.  The 
facts  contained  in  this  brief  chapter  are  taken  from  the  experience 
of  such  military  surgeons  as  Kocher,  Treves,  Nancrede,  Makins, 
Senn,  Borden,  Ta  Garde,  and  others  who  have  during  the  past 
few  years  studied  scientifically  this  important  class  of  wounds. 

In  the  construction  of  the  modern  military  rifle  several  impor- 
tant changes  have  been  made.  The  bore  of  the  rifle  has  been  re- 
duced. The  caliber  of  the  bullet  has  been  lessened.  The  velocity 
of  the  bullet  at  the  muzzle  has  been  increased.  The  trajectory 
is  more  flat.  The  revolution  of  the  bullet  upon  its  long  axis  is 
increased. 

As  a  general  result  of  these  various  changes  the  modern  military 
rifle  has  a  great  range  and  great  accuracy.  The  effect  of  the 
modern  bullet  upon  bone  is  described  as  concisely  as  is  possible  in 
the  following  paragraphs. 

The  amount  of  the  damage  done  to  bone  is  dependent  upon 
several  factors:  The  greater  the  velocity  of  the  bullet  when  the 
bone  is  struck,  the  greater  will  be  the  destruction  of  the  bone. 
The  muzzle  velocity  of  the  modern  bullet  is  ordinarily  about  two 
thousand  feet  a  second.  The  less  the  velocity,  the  less  will  be  the 
destructive  effects.  The  velocity  may  be  just  sufficient  to  break 
the  bone  and  not  to  carry  the  bullet  through  the  limb.  The 
severity  of  the  injury  therefore  decreases  in  proportion  to  the  dis- 
tance which  intervenes  between  the  rifle  and  the  object  struck. 
The  trained  military  surgeon  may  read  the  range  in  the  character 
of  the  damage  done.  The  more  pointed  bullet  secures  for  itself 
greater  penetration  and  perforation.  The  bullet  acts  like  a  steel 
wedge  driven  with  great  velocity  through  the  soft  and  hard  parts. 

431 


GUNSIKIT    FRACTURES    OF    BONE 


The  jirimary  collision  area  is  small.  The  only  indisputable  evi- 
dence of  a  low  velocity  is  the  lodgment  of  an  undcformed  bullet. 
The  resistance  ofTered  by  the  tissues  is  lessened  and  the  resulting 


Fig.  5S6. — Sections  of  bullets  to  show  relative  shape  and  thickness  of  mantles  :  i,  Geudes  : 
regular  dome-shaped  tip  ;  mild  steel  mantle;  thickness  at  tip,  0.8  mm. ;  at  sides  of  body,  0.3 
mm.  ;  2,  Lee-Metford  :  ogival  tip;  cupro-nickel  mantle;  thickness  at  tip,  o.S  mm.;  gradual 
decrease  at  sides  to  0.4  mm. ;  3,  Mauser  :  pointed  dome  tip  ;  steel  mantle  plated  with  copper 
alloy;  thickness  at  tip,  o.S  mm.;  gradual  decrease  at  sides  to  0,4  mm.;  4,  Krag-Jorgensen  : 
ogival  tip  as  in  Lee-Metford;  steel  mantle  plated  with  cupro-nickel;  thickness  at  tip,  0.6 
mm. ;  gradual  decrease  at  sides  to  0.4  mm.  Note  the  more  gradual  thinning  in  the  Lee- 
Metford  (from  Makins'  "  Surgical  E.xperiences,"  etc.). 


Fig.  587. — Four  common  types  of  lateral  Mauser  ricochet  bullets  (from  Makins'  "Surgical 

Experiences,"  etc.). 


wounds  are  neat.  Important  parts  are  seemingly  miraculously 
avoided  by  the  bullet.  The  revolution  of  the  bullet  on  its  long 
axis  facilitates  a  neat  wound  of  entrance  through  the  skin.  The 
Mauser  bullet  revolves  on  its  own  axis  once  in  8j^  inches,   or 


GUNSHOT    FRACTURES    OF    BONE 


433 


about  half  of  a  full  revolution  in  the  perforation  of  a  limb.  The 
amount  of  destruction  suffered  by  any  part  of  a  bone  depends 
primarily  upon  the  amount  of  resistance  which  it  opposes  to  a 
bullet.  There  is  more  resistance  offered  by  the  cortex  found  in 
the  shaft  than  by  the  spongy  tissue  of  the  ends  of  the  long  bones. 
When  the  hard  shaft  or  cortical  bone  is  hit,  the  force  of  the  bullet  is 
expended  in  breaking  this  dense  and  resistant  bone  into  minute 
pieces. 

The  explosive  effect  of  a  bullet  is  dependent  upon  the  velocitv 
remaining  to  be  expended  upon  the  small  particles  of  bone  broken 
off  by  the  initial  impact.  The  carrying  of  these  particles  of  bone 
forward  into  and  through  the  tissues  causes  the  laceration  and 
tearing  so  characteristic  of  the   so-called   explosive  effect  of  a 


Fig.  588.— Five  types  of  fracture  :  a,  Primar\-  lines  of  stellate  fracture  ;  b,  development  of 
the  same  lines  by  a  bullet  traveling  at  a  low  degree  of  velocity  ;  the  two  left-hand  limbs  seen 
in  (a)  absent ;  in  their  places  is  seen  a  transverse  line  ;  c,  typical  complete  wedge  ;  rf,  incom- 
plete wedge;  e,  oblique  single  line  (from  Makins'  "  Surgical  Experiences,"  etc.). 


bullet.     The  detached  bony  particles  become  really  secondarv 
missiles. 

Kocher  has  classified  the  parts  of  the  long  bones  injured  as  the 
diaphysis,  the  epiphysis,  and  the  part  between  the  two,  the  met- 
aphysis.  The  cortical  layer  of  the  metaphysis  is  thin  and  the 
spongy  tissue  is  in  evidence.  Uncomplicated  injuries  of  these 
three  parts  of  the  bone  are  usually  quite  characteristic  (see  Figs. 
590.  595.  603).  The  flat  bones  show  a  clean  perforating  wound 
similar  to  that  seen  in  the  short  bones.  The  cancellous  or  spongy 
tissue  of  bone  is  ordinarily  perforated  completely  and  the  wound 
of  the  bone  is  usually  pretty  clean-cut.  Clean-cut  perforations 
without  fracture  are  the  rule  in  the  neighborhood  of  the  joints  and 
epiphyses  (see  Figs.  591-594).  Makins  noticed  in  South  Africa, 
28 


434 


GUNSHOT    KRACTIRES    OF    BONE 


among  the  wounds  he  studied,  "the  striking  contrast  of  clean 
perforation  and  extreme  comminution  in  different  cases";  "the 
occasional  occurrence  of  fracture  of  a  very  high  degree  of  longi- 
tudinal obliquity"  ;  "the  rarity  of  any  that  could  be  termed  trans- 
verse fractures";  "the  general  tendency  of  longitudinal  fissuring, 
when  it  occurred,  to  stop  short  of  the  articular  extremities  of  the 
bones."     If  explosive  effects  are  but  slightly  marked  it  is  probably 


Fig.  5S9. — Diagranimalic  view  of  a  type 
of  fracture  of  tlie  femur,  the  bullet  entering 
on  the  anterior  surface  of  the  bone  caus- 
ing extensive  longitudinal  Assuring  of  the 
shaft.  The  articular  ends  of  the  same  have 
not  been  involved  in  the  fracture  (after 
KocherJ. 


Fig.  590. — Diagram  of  a  type  of  frac- 
ture. The  entrance  wound  clean-cut,  the 
exit  wound  lacerated  and  larger  than  the 
wound  of  entrance  (after  Kocher). 


because  the  velocity  remaining  was  insufficient  to  impart  enough 
motion  to  the  detached  particles  to  convert  them  into  secondary 
missiles.  The  greater  the  distance  between  the  rifle  and  the 
bone  struck,  the  lower  will  be  the  velocity  of  the  bullet.  Conse- 
quently the  splinters  of  bone  will  be  fewer,  longer,  and  more  ad- 
herent. On  the  contrary,  the  nearer  the  bone  to  the  rifle,  the 
splinters  will  be  more  numerous,  shorter,  unattached,  and  pul- 
verized with  bone  sand. 


Fig.  591. — Upper  end  of  tibia  penetrated 
by  bullet,  showing  clean-cut  wound  with- 
out laceration  of  bone  (La  Garde). 


Fig.  592. — Upper  end  of  tibia  penetrated 
by  bullet.  Slight  fissure  of  shaft  below 
bullet  hole  (La  Garde). 


Fig.  593. — Anterior  surface  lower  end 
of  femur.  Clean-cut  wound  of  entrance, 
fissure  (La  Garde). 


Fig-  594- — Posterior  view  of  Fig.  593. 
Exit  wound.  Note  more  comminution 
than  at  point  of  entrance  (La  Garde). 


435 


436 


GUNSHOT    FRACTURES   OF    BONE 


A  small  skin  wound  may  conceal  a  serious  injury  to  the  bone 
beneath.  The  Hesh  wounds  of  entrance  inilicted  by  the  modern 
rifle  are  mosth-  trivial.  The  missile  with  its  great  velocit)-,  in 
face  of  slight  resistance,  will  retain  nearly  all  its  energy,  imparting 
little  or  none  to  the  tissues.  The  exit  wound  may  be  small  or 
large,  depending  upon  the  presence  or  absence  of  the  explosive 
efl"ect  and  also  upon  the  deflection  of  the  bullet.  Deflection  of  the 
bullet  at  the  distance  at  which  manv  wounds  are  received,   as 


m^^^^Mm 


Fig.  595.— Diagram  of  a  bullet  wound  of  the  metaphysis  of  the  femur.  The  smaller  en- 
trance wound  contrasts  with  the  larger  exit  wound.  The  absence  of  fissuring  is  rather  char- 
acteristic of  bullet  wounds  in  this  region  of  the  ends  of  the  bones  (after  Kocherj. 


pointed  out  by  Xancrede,  occurs  more  commonly  than  is  taught. 
Between  the  discharge  of  a  bullet  and  its  arri\'al  at  the  mark  many 
things  mav  happen  to  it,  resulting  in  a  complicated  wound  of  the 
soft  parts  and  an  extensive  comminution  of  bone. 

The  turning  of  a  bullet  by  impact  with  an  obstacle  in  its  course 
is  spoken  of  as  ricochet.  The  bullet  which  ricochets  may  enter  the 
body  not  necessarily  end  on,  but  in  any  position  and  wobbling 
about.  Under  these  circumstances  the  wound  of  entrance  is 
greatly  increased,    and,    the   velocity   being  impaired,    a  lodged 


GUNSHOT    FRACTURES   OF    BONE 


437 


bullet  often  results.  However,  if  great  velocity  remains,  a 
ricocheting  bullet  may  cause  very  great  damage.  A  ricochet 
bullet  is  dangerous  because  its  penetrative  power  is  diminished, 
it  is  liable  to  be  retained  in  the  tissue,  serious  damage  results  to 


Fig.  596. — Gutter  fracture  of  second  degree,  perforating  the  skull  in  the  center  of  its 
course.  The  external  table  alone  carried  away  at  either  end  (from  Makins'  "  Surgical  Ex- 
periences," etc.). 


F'g-  597- — Illustrating  the  penetrating  power  of  bullets  of  different  material  in  oak  timber 
at  right  angles  to  grain  of  the  wood  (La  Garde). 


the  bone  if  it  is  struck,  and  a  badly  lacerated  wound  may  result 
in  the  soft  parts. 

These  facts  are  perhaps  of  interest :  The  old  flint-lock  ball  was 
-^  inch  in  diameter.  The  Minie  rifle  (Crimean)  ball  was  -^  inch 
in  diameter.  Martini  Henry  ball  was  yq  inch  in  diameter.  The 
modern   small   bore    L,ee-Metford  is  fV  inch   in    diameter.     The 


438 


GUNSHOT    FRACTl'RES    OF    BONE 


Mauser  is  slightly  smaller  than  the  latter.  The  latter  two  bullets 
have  the  new  cupro-nickel  case.  The  others  were  the  old  lead 
bullets.  The  Mauser  bullet  is  1.21  inches  long,  weighs  172.8 
grains,  is  0.275  inch  in  diameter,  has  a  muzzle  velocity  of  238  feet 
per  second,  and  makes  i  turn  to  the  left  every  9  inches.  The 
English  Lee-!Metford  is  1.25  inches  long,  weighs  215  grains,  is  0.303 
inch  in  diameter,  and  has  a  muzzle  velocity  of  2000  feet  per  second. 
As  La  Garde  has  justly  remarked,  the  employment  of  smokeless 
powder,  a  Hatter  trajectorv  and  greater  penetration,  and  the 
change  to  the  smaller  jacketed  projectiles  will  increase  the  number 
of  the  wounded  in  war,  but  the  wounds,  as  a  whole,  will  be  less 


Fig.  598. — Diagrammatic  transverse  section  of  complete  gutter  fracture:  .■},  External 
table  destroyed,  large  fragment  of  internal  table  depressed  (low  velocity  or  dense  bone)  ; 
£,  pulverizatioti  and  comminution  of  both  tables  at  the  center  of  the  track  ;  C,  depression  of 
inner  table  (low  velocity)  (from  Makins'  "  Surgical  Experiences,"  etc.). 


grave — more  humane.  Soldiers  will  be  more  often  restored  to  the 
State  useful  members  of  the  community,  instead  of  cripples  and 
pensioners.  In  point  of  economy  the  new  projectiles  confer  a 
great  advantage. 

Treatment. — The  principles  underlying  the  treatment  of  closed 
fractures  are  to  be  followed  in  the  case  of  gunshot  fractures.  But 
there  are  a  few  considerations  worthy  of  note.  Avoid  exploration 
of  a  fresh  gunshot  fracture  upon  the  field.  Local  examination  to 
determine  the  number,  size,  and  position  of  fragments  is  unwise. 
The  modern  bullet  is  usually  aseptic,  smooth,  and  not  heated. 
There  is  no  urgency  for  its  removal.     It  appears  (Borden)  that 


TREATMENT 


439 


neither  ricochet  passage  through  other  objects  nor  lowered  veloc- 
ity markedly  increases  the  proneness  of  the  jacketed  missile  to 
produce  infection.  The  lodgment  of  a  bullet  does  not  necessitate 
the  treatment  of  the  wound  as  if  it  were  an  infected  one.  The 
dictum  of  von  Nussbaum — "The  fate  of  the  wounded  rests  in  the 
hands  of  the  one  who  applies  the  first  dressing" — applies  nowhere 


Fig.  599. — Clean  gutter  fracture  of  the  ilium  (range  about  300  yards).  The  gutter  was 
clean-cut  and  admitted  the  forefinger.  The  inner  and  outer  tables  of  the  bone  were  in  part 
blown  out  of  a  large,  irregularly  circular  exit  opening  about  i^4  inches  above  the  crest  of  the 
ilium.  The  cancellous  tissue  was  probably  entirely  blown  out.  Plates  of  the  outer  and  inner 
tables  still  remained  connected  by  their  periosteum  to  that  deep  aspect  of  the  iliacus  and 
gluteus  medius  muscles.  The  peritoneal  cavity  was  not  opened.  The  patient  did  well. 
Compare  with  gutter  fracture  of  the  skull,  seen  in  figure  596  (from  Makins'  "  Surgical  Ex- 
periences," etc.). 


with  as  much  force  as  to  the  wounded  in  battle.  The  first  field 
dressing  is  of  the  greatest  importance. 

Consideration  of  gunshot  traumatism  of  the  shaft  of  long  bones, 
as  shown  by  the  Rontgen  ray  in  connection  with  the  ultimate  out- 
come of  the  cases,  points  indubitably  to  the  conclusion  that  in- 
fection or  noninfection  of  the  wound  should  influence  treatment, 
rather  than  the  amount  or  extent  of  bone  damaged  (Borden). 

In  noninfected  wounds  extensive  comminution  is  not,  as  a  rule, 


440  GUNSHOT    FRACTfRES    OF    BONE 

an  indication  for  operative  interference  of  any  kind.  Occlusive 
dressings  and  immobilization  give  assurance  of  the  best  possible 
results.  Where  there  is  ronsiderable  comminution  shortening  of 
the  limb  will  probably  occur  as  a  result  of  the  comminution  and 
the  displacement  of  the  bone  fragments.  But  excellent  functional 
use  of  the  limb  mav  be  restored,  unless  the  lesion  of  the  soft  parts 
is  extensive  and  motion  is  restricted  by  the  formation  of  cicatricial 
connective  tissue  in  the  traumatic  spaces  (Borden). 

Where  infection  exists  removal  of  the  cause  under  aseptic  or 
antiseptic  precautions  is  indicated.  In  such  cases  complete 
cleansing  of  the  wound  and  removal  of  all  loose  bone  fragments, 
followed  by  drainage  and  antiseptic  dressings  and  irrigation,  will 


Fig.  600. — Superficial  perforating  fracture,  illustrating  lifting  of  the  roof  at  both  entry  and 
exit  openings  (from  Makins'  "Surgical  Experiences,"  etc.). 

usually  suffice,  and  excision  or  amputation  will  only  have  to  be 
resorted  to  in  extreme  cases  (Borden).  Amputation  for  extensive 
fracturing  of  the  long  bones  is  almost  unknown  (Xancrede). 

As  to  the  disinfection  of  the  limb,  primary  cleansing,  mainly  by 
soap  and  water,  of  course  should  precede  the  exploration ;  and 
when  the  latter  has  been  carried  out,  a  second  cleansing,  prefer- 
ably with  corrosive  sublimate,  is  imperative. 

Immobilization  is  a  more  difficult  problem.  Makins'  remarks: 
A  question  of  constant  difficulty  is  that  of  frequency  of  dressing. 
In  a  stationary  or  base  hospital  this  is  not  difficult.  When  the 
patient  is,  however,  being  moved  from  the  field  to  the  stationary 
hospital,  and  thence  to  the  base,  the  movements  during  transport 


TREATMENT  44 I 

disturb  the  fixity  of  the  dressing.  No  fractures  of  the  thigh  or 
leg,  and  few  of  the  arm,  can  be  transported  for  any  distance  with- 
out material  disadvantage. 

If  possible,  all  fractures  of  the  arm,  thigh,  or  leg  should  be  kept 
at  a  stationary  hospital  for  a  period  of  three  or  more  weeks. 

The  necessity  for  primary  amputation  chiefly  depends  on  the 
nature  of  the  injury  to  the  soft  parts,  less  commonly  on  the  extent 
of  the  injury  to  the  bones,  and  should  be  decided  on  exactly  the 
same  lines  as  in  civil  practice.  So-called  intermediate  amputa- 
tions are  always  to  be  avoided  if  possible.  The  results  have 
been  bad  and  the  operation  should  only  be  undertaken  in  cases 
of  severe  sepsis  where  little  can  be  hoped  from  it,  or  for  secondary 
hemorrhage.  When  the  operation  could  be  tided  over  until  the 
septic  process  had  settled  down  and  localized  itself,  secondary 
amputation   gave   very  fair  results.     In   either  intermediate  or 


Fig.  601.— Diagrammatic  longitudinal  section  of  fracture  shown  in  figure  600  (from  Makins' 
"  Surgical  Experiences,"  etc.). 


secondary  amputation  for  suppurating  fractures  it  was  necessary 
to  bear  in  mind  the  special  likelihood  of  an  extensive  osteomye- 
litis (Makins). 

The  very  great  mortality  attending  gunshot  fracture  of  the 
femur  previous  to  the  introduction  of  the  small-bore  rifle  makes  it 
important  to  consider  this  fracture  in  some  detail.  I  quote 
Makins  as  having  had  the  best  recorded  clinical  experience  in 
these  cases. 

First  with  regard  to  the  primary  signs  and  symptoms.  A  very 
considerable  degree  of  general  or  constitutional  shock  usually 
accompanied  them,  and  this  was  perhaps  more  constant  than  in 
the  case  of  any  other  injury  in  the  body.  Local  shock  to  the  part 
was  also  a  prominent  feature.  Abnormal  mobilitv  was  verv  free 
in  the  badly  comminuted  cases.  Crepitus  was  often  loose,  and  of 
the  "bag-of-bones"  variety.  The  result  of  local  shock  and  con- 
sequent flaccidity  of  the/ muscles  was  to  reduce  the  development 


44- 


GU.N'SIIUT    l-'KACTLRHS    UK    BONE 


of  primary  shortenins: :  in  some  cases  of  severe  comminution  this 
was  practically  ;///  during  the  first  day  or  two,  when,  with  return 
of  tone  in  ihe.  uuiscles,  it  sometimes  became  very  considerable. 

The  long  and  dillicult  transport  is  the  most  unsatisfactory 
element  to  contend  with  in  the  treatment  of  fractures  of  bone  in 
the  field.  There  are  advantages  in  having  a  field  hospital  behind 
the  firing  line.     vSir  W'm.  MacCormac  has  said  that  the  ideal  treat- 


Fig.  602. — Perforation  of  lower 
third  of  tibia,  showing  lifting  and 
Assuring  of  the  compact  roof  of  the 
tuiniel.  Compare  with  figure  600, 
of  a  fracture  of  the  cranial  vaults 
(from  Makins'  "  Surgical  Experi- 
ences "  etc.). 


Fig.  603. — Oblique  perforation,  implicating  both 
epiphysis  and  diaphysis.  Large  fragment  detached 
at  e.xit  aperture.  Caused  by  a  bullet  traveling  at 
a  low  rate  of  velocit\-.  The  dotted  lines  indicate 
the  course  of  the  track  (from  Making'  "  Surgical 
Experiences,"  etc.). 


ment  of  a  gunshot  fracture  of  the  femur  would  be  to  erect  a  tent 
over  the  man  where  he  fell  and  not  to  transport  him  at  all. 

The  plaster-of- Paris  splint  (roller  bandage)  spica  to  both  thighs, 
with  a  long  outside  splint  from  axilla  to  below  the  foot,  is  the  most 
satisfactory  immobilization  apparatus  for  these  cases  of  compound 
thigh  fracture. 

The  operative  mortality  following  compound  or  open  fractures 
of  the  femur  during  the  Crimean  war  was  about  73  per  cent.  Dur- 
ing the  American  war  it  was  about  53  per  cent.  During  the 
Franco-German  war  it  was  65  per  cent,  among  the  Germans  and 
90  per  cent,  among  the  French.     The  conservative  mortality — 


PROGNOSIS    IN    FRACTURES    OF    FEMUR  443 

i.  e.,  in  the  unoperated  cases — was,  under  these  same  conditions: 
Crimean  war,  72  per  cent. ;  American  war,  49  per  cent. ;  Franco- 
German:  German,  28  per  cent.;  French,  9  per  cent.  In  the  re- 
cent war  with  Spain  in  Cuba,  although  the  results  are  not  all 
tabulated,  during  1898-99  the  general  mortality  in  operated  and 
unoperated  cases  together  was  but  10  per  cent,  in  this  serious 
injury.  Modern  surgical  methods  used  upon  wounds  of  bone 
caused  by  modern  military  weapons  will  bring  the  mortalitv-rate 
very  low  indeed.  All  those  interested  in  this  department  of 
surgery  will  await  final  statistics  with  hopeful  expectation. 

Prognosis  in  Fractures  of  the  Femur. — From  Makins'  "Sur- 
gical Experiences"  :  "As  regards  mortality,  fractures  in  the  upper 
third  of  the  bone  proved  one  of  the  most  formidable  injuries  which 
came  under  treatment.  Suppuration  was  common,  at  least  60 
per  cent,  of  the  wounds  becoming  infected.  This  depended  on 
several  reasons,  often  inseparable  from  the  injuries,  or,  from  their 
treatment  in  field  hospitals;  such  as  (i)  the  exit  wound  being 
situated  in  the  dangerous  region  of  the  thigh ;  (2)  ineffective  dress- 
ing and  fixation ;  (3)  the  impossibility  of  insuring  primary  cleansing 
and  removal  of  detached  fragments  of  bone;  (4)  the  necessity  of 
the  early  transport  of  patients  to  the  stationary  or  base  hospitals, 
often  for  great  distances;  (5)  the  comparatively  long  period  that 
often  had  to  elapse  before  the  opportunity  of  doing  the  first  efifi- 
cient  dressing  arrived.  Fractures  in  the  middle  and  lower  thirds 
of  the  bone  were  more  easy  to  treat  successfully,  but  these  also 
added  to  the  list  both  of  amputation  and  fatalities.  Punctured 
fractures  of  the  lower  articular  extremity  were  usually  of  little 
importance,  as  they  progressed  without  exception,  as  far  as  mv 
experience  went,  favorably." 


CHAPTER  XVIII 

THE  RONTGEN  RAY  AND  ITS  RELATION  TO 
FRACTURES 

BV  E.   A.   CODMAN,  M.D. 

On  January  23,  1896,  Rontgen  read  his  announcement  of  the 
discovery  of  the  X-rays  before  the  Physico-medical  vSociety  at 
Wurzburg.  The  extraordinary  news  fled  oyer  the  world  in  an 
incredibly  short  time.  \\'ithin  a  few  months  skiagraphs  of  the 
bones  of  the  hands  appeared  in  eyery  newspaper  that  could  afford 
an  illustration,  and  the  reporters  indulged  their  imaginations  and 
dwelt  on  the  advantages  the  new  discovery  would  bring  to  medi- 
cine and  surgery.  The  strangeness  of  the  subject  offered  an  un- 
usually brilliant  field  for  the  imaginative  and  humorous,  and  in 
consequence  it  will  undoubtedly  be  years  before  the  public  is  dis- 
abused of  its  first  erroneous  impressions.  Perhaps  more  people 
err  now  on  the  side  of  incredulity  than  credulity,  and  are  inclined 
to  regard  the  wonders  they  heard  of  at  first  as  "newspaper  talk." 
Medical  men  are  particularly  subject  to  this  criticism,  and  there 
are  many  who  seem  to  feel  a  disappointment  in  the  results.  It  is 
unfortunate  that  Rontgen's  original  article  was  not  widely  pub- 
lished in  the  first  place,  for  it  is  a  model  of  scientific  accuracy,  and 
contains  not  a  single  statement  that  has  not  been  substantiated 
again  and  again.  To  those  men  who  understood  the  limitations 
of  the  X-ray  that  this  article  pointed  out,  the  results  have  not 
been  disappointing.  On  the  contrary,  the  improvements  in  appa- 
ratus and  technic  have  enlarged  the  scope  of  its  use  and  increased 
the  importance  of  the  information  it  gives  us.  The  X-ray  depart- 
ment has  become  a  necessity  in  every  general  hospital. 

In  discussing  the  value  of  Rontgen's  discovery  in  a  book  on  the 
treatment  of  fractures  it  has  seemed  wise  to  point  out  some  of  the 
mistakes  that  are  commonly  made  in  the  interpretation  of  skia- 
graphs.    To  those  who  have  done  practical  work  with  the  X-rays 

444 


MISTAKES    IN    INTERPRETATION    OF    SKIAGRAPHS  445 

this  chapter  will  be  valueless;  but  those  who  have  not  may  find 
in  it  some  assistance  in  their  effort  to  learn  what  real  value  the 
new  science  is  to  this  branch  of  surgery. 

Among  other  misconceptions  the  Crookes  tube  was  supposed 
to  emit  a  very  powerful  light.  It  is  not  a  powerful  light,  but 
merely  a  faint  one  of  such  quality  that  it  is  able  to  penetrate  sub- 
stances that  ordinary  light  does  not.  It  is  its  peculiar  quality,  not 
its  intensity,  that  enables  it  to  penetrate  opaque  objects.  It  is 
invisible  to  our  eyes,  but  has  the  quality  of  causing  chemical  action 
on  a  photographic  plate  or  of  affecting  crystals  of  certain  sub- 
stances so  as  to  make  them  emit  a  faint  light.  A  sort  of  sand- 
paper made  of  these  crystals,  finely  ground,  forms  a  fluorescent 
screen.  A  ffuoroscope  is  made  by  inclosing  such  a  screen  in  a 
light  tight  box  with  an  eyepiece  to  allow  the  observer  to  see  the 
crystal  side  of  the  sand-paper.  When  this  instrument  is  brought 
near  a  Crookes  tube  in  action,  the  crystals  become  luminous  and 
any  substance  that  is  not  easily  penetrated  by  these  rays,  when 
placed  between  the  source  of  light  and  the  screen,  will  cut  off  the 
rays  and  cast  a  shadow  on  the  sand-paper  that  can  be  seen  on  the 
side  away  from  the  object.  This  shadow  will  be  more  or  less  deep, 
according  to  whether  the  substance  cuts  off  more  or  less  rays. 
Thus,  iron  casts  a  darker  shadow  than  wood;  bone,  a  darker 
shadow  than  flesh.  In  general  the  opacity  of  different  substances 
varies  directly  with  their  atomic  weights.  In  the  same  way  the 
substance  placed  between  the  source  of  light  and  a  photographic 
plate  will  cut  off  some  of  the  rays  from  the  plate.  Where  these 
are  cut  off,  chemical  action  does  not  occur ;  where  some  of  the  rays 
go  through  it  occurs  slightly;  where  the  object  does  not  interfere 
at  all  and  the  rays  strike  the  plate  directly,  the  action  is  greatest. 
When  the  plate  is  developed,  we  get  a  picture  of  the  shadow  of  the 
object  with  its  most  dense  parts  most  deeply  shaded. 

Many  people  confuse  an  X-ray  picture  with  a  photograph. 
They  take  it  to  be  a  photograph  by  X-ray  light.  It  is  not  a  photo- 
graph, but  a  shadow-picture,  a  compound  silhouette,  a  projec- 
tion of  the  parts  of  an  object.  A  photograph  of  the  hand  is  made 
by  the  light  reflected  from  the  hand  to  the  photographic  plate,  and 
shows  the  surface  of  the  skin.  A  skiagraph  of  the  hand  is  made 
.by  the  light  that  has  passed  through  the  hand,  and  shows  a  chart  of 


446   THE  ROXTGEX  RAV  AND  ITS  RELATION  TO  FRACTURES 

the  dilTcrent  densities  of  the  dilTerent  coiislilueiils  of  the  hand,  as 
bone,  muscle,  fat.  and  skin.  As  the  other  parts  of  the  hand  are  of 
about  equal  density  and  this  density  is  much  less  than  that  of  bone, 
the  bones  appear  prominently  on  the  chart.  The  thickest  portions 
and  most  dense  portions  of  the  bone  appear  more  deeply  marked 
than  the  lighter  and  spongy  j^ortions.  As  every  little  gradation  of 
density  is  registered,  the  whole  forms  a  picture. 

As  far  as  we  know,  the  effects  of  the  X-rays  are  only  obtainable 
in  the  immediate  neighborhood  of  their  course;  that  is,  a  small 
point  on  the  platinum  reflector  in  the  Crookes  tube.  From  this 
point  they  radiate  in  all  directions,  their  power  gradually  dimin- 
ishing until  at  a  distance  of  about  a  hundred  feet  or  a  little  more 
they  are  not  appreciable  by  any  means  now  at  our  command. 
Practically,  they  are  only  strong  enough  for  skiagraphic  purposes 
within  a  few  feet  of  the  tube. 

Since  they  proceed  from  a  point,  and  are  not  approximately 
parallel  like  the  sun's  rays,  their  shadows  are  necessarily  distorted. 
We  are  all  familiar  with  the  distorted  shadows  thrown  on  the  wall 
by  a  candle.  The  same  distortion  takes  place  in  an  X-ray  picture 
in  a  lesser  degree.  vSince  the  rays  proceed  from  a  point,  all  parts 
of  an  object  can  not  stand  in  the  same  relation  to  that  point  and 
the  surface  of  a  plate  at  the  same  time.  The  least  distortion  will 
take  place  when  the  object  is  in  contact  with  the  plate,  and  as  far 
from  the  light  as  is  consistent  with  obtaining  sufficient  effect  to 
take  the  picture :  that  is,  to  have  the  rays  penetrate  the  less  dense 
portions  of  the  object.  Let  the  distance  from  the  point  to  the 
plate  remain  the  same.     It  follows  that : 

(a)  Shadows  will  be  enlarged  in  proportion  to  the  distance  of 
the  object  from  the  plate,  toward  the  light. 

(6)  Shadows  are  distorted  of  any  object  or  part  of  an  object  not 
in  a  perpendicular  line  from  the  point  of  light  to  the  surface  of  the 
plate,  and  that  distortion  takes  place  in  a  line  drawn  from  the 
base  of  such  perpendicular  through  that  object  or  part  of  an  object. 

As  an  illustration  of  these  distortions,  we  have  represented  in 
figure  604  the  projection  of  a  cubical  block  of  wood  (a).  For  con- 
venience of  drawing,  the  shadow  (b)  is  presented  at  an  angle. 
The  outside  square  of  b  represents  the  upper  surface  of  the  block, 
while  the  inner  square  represents  the  lower.     The  density  of  the 


the;  interpretation  of  skiacraphs 


447 


shadow  is  greatest  at  the  edges  of  the  lower  square,  for  they  rep- 
resent the  longest  paths  of  the  rays  through  the  block.  From 
the  consideration  of  figures  605,  606,  607,  and  608  the  reader  will 
readily  observe  that  any  change  in  the  tilt  of  the  plane  of  the  plate 
(Fig.  606,  a)  in  the  shape  or  density  of  the  object,  or  in  the  dis- 
tance of  the  point  of  light  (Fig.  607),  will  produce  a  definite  altera- 
tion of  the  shadow  or  picture.     It  is,  therefore,  necessary  in  looking 


T^J^ 


Fig.  604. 


at  a  skiagraph  to  know  how  the  plane  of  the  plate  lay,  how  far 
distant  the  light  was,  and,  in  general,  what  the  shape  and  density 
of  the  different  parts  of  the  object  were. 

Just  as  it  is  true  that  the  shadow  of  any  object  increases  in  size 
as  it  is  moved  from  the  plate  toward  the  light,  so  also  it  is  true 
that  the  density  of  the  shadow  decreases  as  its  size  increases. 
Each  object  that  is  translucent  to  the  X-rays  seems  to  have  the 
ability  to  cut  off  a  certain  amount  of  X-ray  light.     In  other 


44^      THE    ROXTGEX    RAV    AXD    ITS    RELATION    TO    FRACTIRES 

words,  it  contains  a  certain  amount  of  shadow-casting  material. 
As  it  is  moved  from  the  plate  toward  the  Hglit  its  shadow  increases 


Plalc 


TLate 


^_  ?Ute 


TLale 


Fig.  606. 


in  size,  but  diminishes  in  density,  since  only  a  certain  amount  of 
light  can  be  obstructed  by  that  object. 


THE  INTERPRETATION  OF  SKIAGRAPHS 


449 


Putting  it  in  another  way,  we  see  that  the  object  x  y  (I'ig.  605) 
in  the  angle  ah  c  interferes  with  three  times  as  much  Hght  as  if  in 
the  position  oi  a  d  e,  but  since  it  can  only  cut  off  a  certain  quantity 
of  rays  in  either  position,  the  shadow  in  d  e  will  be  darker,  though 
smaller  than  b  c.  Of  course,  \i  x  y  were  not  penetrated  at  all  by 
the  rays,  the  shadow  would  be  at  a  maximum  in  both  cases.  In 
ah  c  there  are  three  times  as  many  rays  to  go  through,  but  x  y  can 
only  subtract  a  certain  number.  It  can  subtract  that  number 
from  a  d  e  where  there  will  be  a  smaller  remainder  and  hence  a 


Fig.  607. 


deeper  shadow.  This  is  an  especially  important  point  to  keep  in 
mind,  for  the  range  of  variation  of  density  of  different  bones  is 
very  small,  and  a  very  slight  change  in  position  in  relation  to  the 
plate  may  make  an  enormous  difference  in  the  resulting  picture. 
For  example,  figure  609,  a  skiagraph  of  the  knee  taken  from  be- 
hind,— i.  e.,  with  the  plate  behind, — C  shows  little  or  no  sign  of 
the  patella.  While  with  the  plate  in  front  {B)  and  the  tube  be- 
hind, the  outline  of  the  patella  is  distinguishable  through  the 
shadow  of  the  femur.  This  is  the  more  decided  if  the  tube  is 
brought  quite  near  to  the  back  of  the  knee  {A ) ,  for  then  the  size  of 
29 


450   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

the  shadow  of  the  femur  is  increased  and  its  density  diminished, 
while  that  of  the  patella  remains  nearly  the  same  in  both  size  and 
density. 

Another  point  that,  though  simple,  seems  to  cause  misunder- 
standing is  illustrated  in  figure  60S,  representing  the  shadow  of  a 
section  of  one  of  the  cylindrical  bones.  It  is  intended  to  show- 
why  a  long  bone  appears  like  a  longitudinal  section  in  a  skiagraph. 
Though  the  whole  circumference  may  be  of  the  same  thickness, 
the  rays  that  pass  through  the  sides,  x-y,  meet  more  resistance 


TT^ie 


TuSe 


TlaU 


PlaU 


Fig.  609. 


than  those  through  the  center ;  hence  the  medullary  cavity  appears 
on  the  plate. 

It  is  often  of  great  assistance  to  plot  out  on  paper  a  projection  of 
the  salient  points  of  the  subject,  as  in  figure  604,  at  the  same  time 
bearing  in  mind  that  variations  occur  in  density  as  well  as  in  size. 
We  should  like  to  go  into  the  question  of  the  deceptiveness  of  skia- 
graphs at  greater  length,  because  we  regard  it  as  of  the  utmost 
importance  that  everv  phvsician  who  uses  this  means  of  diagnosis 
should  fully  understand  the  way  in  which  any  conclusion  should  be 
drawn  from  one  of  these  pictures.  Though  the  pictures  themselves 
are  inaccurate  as  pictures  of  the  object,  they  are  accurate  pictures  of 


ITS    PRACTICAL    VALUE  451 

the  shadows  of  the  different  parts  of  the  object,  and  the  reasoning  of 
conclusions  drawn  from^  them  should  he  exact. 

In  answer  to  the  question  of  what  help  the  X-ray  has  been  in 
increasing  our  knowledge  of  the  pathology  and  treatment  of  frac- 
tures, we  may  mention  first  the  general  points  and  then  the  par- 
ticular fractures  in  which  we  find  it  to  be  of  benefit.  Although 
surgeons  have  always  realized  very  nearly  accurately  the  position 
of  the  displaced  fragments  in  the  common  fractures,  there  can  be 
no  doubt  that  the  production  of  pictures  of  the  exact  condition 
in  individual  cases  gives  more  reliable  information  of  the  condition 
and  relation  of  the  broken  ends  that  can  possibly  be  obtained  by 
palpation.  A  more  definite  knowledge  of  the  pathology  brings 
greater  exactness  of  treatment.  When  the  splints  are  applied,  it 
can  be  ascertained  whether  the  position  is  good  without  removing 
the  bandages.  Little  details  that  otherwise  would  escape  notice 
are  brought  out.  The  patient  is  spared  painful  manipulation  or 
etherization  and  the  bruising  and  laceration  of  the  tissues  from 
unnecessary  handling.  The  question  of  a  cutting  operation  to 
reduce  otherwise  intractable  fragments  may  be  decided  by  an 
exact  knowledge  of  the  positions  of  the  parts.  This  subject  of 
the  advisability  of  interference  by  making  a  simple  fracture 
compound  is  one  that  is  attracting  more  and  more  attention, 
and  will  lead  to  its  being  made  the  rule  in  cases  where  a  good 
result  can  not  be  expected  by  the  simple  method.  When  asepsis 
can  be  practised,  there  is  little  danger  of  making  an  incision,  and 
the  time  saved  in  cases  where  approximation  of  the  fragments  is 
prevented  by  loose  bits  of  bone  or  soft  parts  is  well  worth  this 
slight  risk. 

At  present  we  find  the  X-rays  of  more  assistance  in  the  study  of 
the  pathology  of  fractures  than  we  do  in  their  treatment.  For 
though  we  believe  that  in  each  individual  case  of  fracture  a  skia- 
graph is  of  decided  assistance,  yet  it  must  be  confessed  that  the 
cases  where  it  leads  us  to  modify  the  treatment  to  any  consider- 
able extent  are  few  in  number.  An  exact  diagnosis  of  fracture 
without  skiagraphs  is  always  open  to  doubt,  while  with  a  careful 
X-ray  examination  there  is  seldom  a  doubt.  We  appreciate  the 
X-ray,  too,  when,  after  applying  our  splints,  even  if  plaster,  we 
assure  ourselves  of  the  correct  alinement  of  the  bones. 


45-       '1"H    RONTGEX    RAV    AXU    ITS    KUUATIOX    TO    FRACTURES 

As  a  means  of  demonstrating  to  students  the  pathology  of  frac- 
tures, a  series  of  lantern-slides  of  skiagraphs  is  of  the  greatest 
assistance.  The  knowledge  that  the  pictures  are  of  actual  cases 
and  not  theoretic  diagrams  gives  a  practical  interest  that  is  akin 
to  clinical  instruction.  The  plates  when  shown  at  the  same  time 
as  the  case  at  a  hospital  clinic  also  serve  to  illustrate  the  pathology 
and  indications  for  treatment. 

A  not  unimportant  result  of  the  use  of  Rontgen's  discovery  is 
the  exactness  it  offers  as  a  method  of  record  in  the  rarer  fractures. 
Heretofore  statistics  on  the  uncommon  forms  of  fracture  have 
always  been  open  to  the  doubt  of  mistaken  diagnoses,  and  we  have 
been  dependent  on  the  chance  of  securing  postmortem  specimens 
in  order  to  obtain  accuracy.  In  future  the  recorded  cases  of  this 
kind  can  be  illustrated  by  skiagraphs,  and  we  may  look  forward  to 
not  only  greater  accuracy,  but  to  a  much  greater  number  of  cases 
that  were  formerly  considered  rare.  Every  large  hospital  will  be 
able  to  turn  to  its  records  and  say  definitely  in  wdiat  percentage 
anv  given  fracture  occurred.  At  the  same  time,  each  individual 
case  has  the  benefit  of  a  definite  record,  and  the  result  can  be  com- 
pared with  the  extent  of  injurv. 

The  reader  will  now  ask  in  what  forms  of  fracture  can  we  say  the 
X-ray  is  of  great  assistance.  In  general,  those  bones  that  can  be 
brought  near  the  plate  or  that  are  not  overshadowed  by  other 
bones  give  the  most  satisfactory  skiagraphs.  Therefore,  little  can 
be  expected  of  skiagraphs  of  the  bones  of  the  head  or  vertebrae, 
while  those  of  the  extremities  come  out  with  great  precision.  The 
pelvic  and  shoulder  bones  stand  midway  between  these,  but  with 
a  good  apparatus  and  care  in  the  choice  of  the  relative  positions  of 
the  plate,  tube,  and  the  particular  portion  of  the  bone  to  be  taken, 
we  may  expect  a  definite  picture.  Even  in  the  case  of  the  skull 
and  vertebrae  we  occasionallv  find  a  skiagraph  of  advantage.  The 
entire  contour  of  the  lower  jaw  can  be  easilv  investigated ;  the 
nasal,  alveolar,  and  mastoid  processes  and  malar  bones  come  out 
sharply;  the  cervical  vertebrae,  both  from  behind  and  from  the 
side,  can  be  brought  out  with  great  detail,  while  the  dorsal  and 
lumbar,  though  not  appearing  clearly,  sometimes  show  the  rough 
outlines  of  bodies  and  articular,  transverse,  and  spinous  processes. 
Any  particular  portion  of  any  particular  rib,  except  the  necks,  can 


ITS    PRACTICAL    VALUE  453 

be  taken  with  great  accuracy;  since  the  plate  can  be  laid  almost 
directly  upon  it.  The  clavicle,  too,  comes  out  clearly.  The  ster- 
num is  too  much  overshadowed  by  the  dense  dorsal  vertebrae  to 
show  definite  outlines. 

Fractures  in  the  shoulder-joint  are  often  impossible  to  recognize 
without  the  X-ray,  particularly  in  those  cases  where  the  swelling 
and  effusion  about  the  joint  prevent  manipulation.  Fractures  of 
the  tuberosities  of  the  humerus,  of  the  surgical  and  anatomical 
necks,  can  be  differentiated  with  great  certainty.  When  separa- 
tion and  dislocation  of  the  epiphysis  have  occurred,  we  may  decide 
the  question  of  operation;  and  the  same  question  may  be  answered 
in  those  puzzling  cases  in  which  fracture  of  the  neck  has  occurred 
with  dislocation.  Separation  of  the  tuberosities  we  now  find  is  a 
much  more  common  accident  than  we  had  supposed.  Even  in 
breaks  of  the  shaft  of  the  humerus  and  the  other  long  bones  we 
gain  much  information.  The  extent,  direction,  and  plane  of  cleav- 
age, with  the  exact  amount  of  displacement,  are  guides  for  the 
application  of  padding  and  splints.  It  is  in  fractures  of  the  long 
bones  particularly  that  a  second  series  of  skiagraphs  with  the 
splints  in  position  is  of  value.  The  amount  of  shortening  is 
shown  more  accurately  than  by  measuring  the  landmarks,  for  the 
overlapping  can  be  distinctly  seen.  If  necessary,  the  approxima- 
tion of  the  fragments  can  be  aided  by  proper  pads. 

It  is  not  out  of  place  here  to  refer  again  to  the  question  of  dis- 
tortion, for  in  these  cases  one  must  remember  that  not  only  may 
the  bones  be  magnified,  but  also  the  interspace  between  them. 
Two  or  more  pictures  must  be  taken,  for  a  view  from  the  side  will 
often  show  a  displacement  that  is  not  brought  out  in  the  shadow 
from  in  front  or  behind.  The  fluoroscope  is  particularly  useful  in 
this  sort  of  work,  for,  while  it  does  not  give  the  detail  that  can  be 
seen  in  a  plate,  it  is  clear  enough  to  assure  one  of  the  alinement  of 
the  parts  and  avoids  the  trouble  of  taking  and  developing  the 
plates.  In  general  work,  however,  we  place  less  reliance  on  the 
fluoroscope  than  on  the  skiagraph.  As  will  be  pointed  out  later, 
the  use  of  the  fluoroscope,  also,  is  not  without  danger  of  dermatitis. 

It  is  in  injuries  about  the  elbow-joint  that  we  must  be  more  than 
ever  upon  our  guard  to  avoid  false  conclusions  from  the  distor- 
tions that  we  have  endeavored  to  point  out.     It  will  be  most  use- 


454       'l""l^    RONTGHX    RAV    AXD    ITS    RELATION'    TO    FRACTURES 

fill  to  anv  practitioner  who  intends  to  do  X-ray  work  to  take  a 
series  of  skiagraphs  of  the  normal  clI)ow-ioint  from  different  posi- 
tions and  in  different  positions,  and  to  study  most  carefully  the 
projections  of  the  parts  in  each.  Such  a  series  of  injuries  occur  in 
this  region  that  the  diagnoses  are  most  difficult,  and  the  skiagraph 
correctly  interpreted  is  of  the  greatest  help.  Cases  that  formerly 
appeared  in  hospital  records  as  "injury  to  elbow"  are  now  divided 
into  "fractures  of  head  of  radius,"  'neck  of  radius,"  "separation 
of  coronoid  process,"  etc.  A  feature  which  is  now  thoroughly 
brought  out  is  the  common  occurrence  of  fracture  with  disloca- 
tion. Injuries  to  the  elbow  are  particularly  puzzling  in  children, 
since  the  ossification  of  the  epiphyses  is  found  in  different  stages, 
and  the  cartilaginous  portions  do  not  show  in  our  plates.  AVe 
may  expect  better  results  in  this  field  when,  by  study  and  expe- 
rience, we  learn  more  of  the  time  and  mode  of  formation  of  the 
epiphyses. 

In  the  wrist  Rontgen's  discovery  has  taught  us  much.  We  find 
in  the  fracture  of  the  lower  end  of  the  radius  a  variety  of  types. 
Breaking  of  the  stvloid  of  the  ulna  is  found  to  exist  much  more 
often  than  was  supposed.  The  styloid  of  the  ulna  was  fractured 
in  So  per  cent,  of  140  cases  of  Colles'  fracture.  Fracture  of  the 
scaphoid  is  also  not  uncommon  both  alone  and  in  conjunction  with 
Colles'  fracture.  Fractures  of  the  semilunar  and  os  magnum  are 
also  reported.  The  metacarpals  and  phalanges  offer  a  less  inter- 
esting field,  but  in  the  former,  when  impaction  into  the  distal  ex- 
tremity has  occurred  and  it  is  impossible  to  obtain  crepitus  or 
mobility,  a  skiagraph  shows  clearly  the  condition. 

Improvements  in  apparatus  and  technique  have  enabled  us  to 
get,  as  a  rule,  clear  pictures  of  the  upper  extremity  of  the  femur 
when  normal  or  recently  broken.  When  diseased  or  surrounded 
by  much  inflammatory  thickening  or  calcareous  deposit,  the  out- 
lines are  blurred  and  unsatisfactory,  but  yet  throw  light  on  the 
diagnosis.  There  are  often  puzzling  cases  when  fracture,  dis- 
location, tuberculosis,  and  coxa  vara  all  have  to  be  considered,  and 
in  which  a  skiagraph  is  of  the  greatest  assistance.  Any  portion  of 
the  shaft  of  the  femur  can  be  taken,  and,  since  portable  X-ray 
apparatus  have  come  into  use,  the  picture  mav  be  obtained  with- 
out disturbing  the  patient  or  his  dressings.     Of  the  knee  we  get 


THE    LOCAL    EFFECT    OF    THE    RONTGEN    RAY  45.5 

very  clear  plates.  Of  the  method  of  taking  the  patella  we  have 
already  spoken.  We  can  compare  the  results  of  the  traction  treat- 
ment with  those  of  suture  and  wiring.  It  is  of  assistance  in  deter- 
mining whether  the  fragments  are  not  too  much  shattered  to  ad- 
mit of  wiring. 

In  injuries  of  the  lower  leg  we  may  apply  what  has  already  been 
said  of  the  other  long  bones,  and  in  addition  mention  a  case  in 
which  a  fragment  from  the  external  malleolus  lodged  back  of  the 
astragalus  under  the  tendo  Achillis.  In  the  foot,  as  in  the  wrist, 
the  X-ray  has  taught  us  much.  Numerous  cases  of  breaks  in  the 
OS  calcis,  astragalus,  and  scaphoid  have  been  reported,  and, 
though  fractures  of  the  other  tarsal  bones  have  not  fallen  within 
our  experience,  their  occurrence  might  easily  be  recognized. 
Gocht  points  out  that  many  swollen  feet  of  uncertain  diagnosis 
prove  to  be  fractures  of  the  metatarsals.  He  also  reports  frac- 
ture of  one  of  the  sesamoid  bones  of  the  great  toe. 

It  is  commonly  said  that  the  X-ray  is  dangerous  to  the  patient 
and  burns  the  skin  and  destroys  the  hair.  This  is  true  as  a  pos- 
sibility, but  nowadays  is  only  to  be  feared  in  connection  with  gross 
ignorance  and  carelessness.  It  is  a  fact  that  Crookes'  tube  in 
action  is  capable  of  causing  an  effect  on  the  tissues  similar  in  many 
respects  to  a  burn.  But  this  action  does  not  take  place  unless  the 
tissues  are  exposed  to  the  tube  for  a  considerable  period  of  time 
and  at  a  very  short  distance.  For  instance,  eight  inches  from  the 
tube  for  an  exposure  of  five  minutes  we  should  consider  perfectly 
safe;  one  inch  from  the  tube  and  five  minutes,  dangerous.  Dan- 
ger increases  as  we  prolong  the  time  of  exposure  or  diminish  the 
distance  of  the  tube  from  the  skin.  Repeated  exposures  at  short 
intervals  are  approximately  equivalent  in  time  to  one  exposure 
■equal  to  the  sum  of  all.  Probably  the  skins  of  different  people 
vary  in  susceptibility  to  this  influence,  but  we  doubt  if  injury  ever 
occurred  unless  the  tube  was  within  a  foot  of  the  patient. 

Danger  to  the  hands  of  the  operator  of  the  apparatus  is  quite 
another  matter,  for  repeated  exposure  may  produce  the  same  con- 
dition. The  most  severe  cases  occur  when,  in  the  use  of  the  fluoro- 
scope,  the  operator  puts  his  hand  near  the  tube,  either  to  hold  the 
patient's  limb  in  place  or  to  demonstrate  the  bones  of  his  hand  to 
.an  audience.     Physicians  who  are  called  upon  to  use  the  fluoro- 


456   THE  RONTGEN  RAV  AND  ITS  RELATION  TO  FRACTl'RES 

scope  (ifu-n  slioiikl  wear  nil)ber  gloves  to  proleet  llie  hands,  or. 
cover  the  tube  with  a  grounded  aluminium  screen.  Most  of  the 
recorded  cases  of  severe  injury  took  place  when  the  new  light  was 
first  used,  and  experience  had  not  pointed  out  these  cautions. 
To-da\-,  with  our  improved  apparatus,  the  penetration  and  defi- 
nition render  a  closer  approach  to  the  tube  than  twelve  inches  un- 
necessarv.  The  cause  of  these  burns  has  been  a  subject  of  much 
discussion,  and  it  may  still  be  considered  an  open  question.  There 
are  many  who  believe  it  to  be  due  to  an  electrostatic  effect,  while 
others,  among  whom  is  Professor  Elihu  Thomson,  affirm  that  the 
Rontgcn  rays  themselves  are  responsible.  Professor  Thomson 
certainlv  should  be  an  authority  on  this  point,  for  he  has  not  only 
the  advantages  of  his  electrical  knowledge,  but  also  of  experi- 
mental experience.  The  following  is  a  quotation  from  a  personal 
letter  from  him  in  November,  1896,  describing  a  somewhat  heroic 
experiment. 

"Hearing  of  the  effects  of  the  X-rays  on  the  tissues,  especially 
on  the  skin,  I  determined  to  find  out  what  foundation  the  state- 
ments had  by  exposing  a  single  finger  to  the  rays.  I  used  for  this 
the  little  finger  of  the  left  hand,  exposing  it  close  up  to  the  tube, 
about  one  and  one-quarter  inches  from  the  platinum  source  of  the 
rays,  for  one-half  an  hour.  For  about  nine  days  very  little  effect 
was  noticed ;  then  the  finger  became  hypersensitive  to  the  touch, 
dark  red,  somewhat  swollen,  stiff;  and  soon  after,  the  finger  began 
to  blister.  The  blister  started  at  the  maximum  point  of  action  of 
the  rays,  spread  in  all  directions  covering  the  area  exposed,  so  that 
now  the  epidermis  is  nearly  detached  from  the  skin ;  underneath 
and  between  the  two  there  is  a  formation  of  purulent  matter  that 
escapes  through  a  crack  in  the  blister.  It  will  be  three  weeks  to- 
dav  since  the  exposure  was  made,  and  the  healing  process  seems  to 
be  as  slow  as  the  original  coming  on  of  the  trouble." 

Four  days  later:  "The  whole  epidermis  is  off  the  back  of  the 
finger  and  off  the  sides  of  it  also,  while  the  tissue  even  under  the 
nail  is  whitened  and  probably  dead,  ready  to  be  cast  off.  The 
back  of  the  finger  for  a  considerable  extent,  where  it  received  the 
strongest  radiation,  is  raw  and  will  not  recover  its  epidermis,  ap- 
parently, except  from  the  sides  of  the  wound." 

Not  entirely  satisfied  with  this  experiment.  Professor  Thomson. 


MEDICOLEGAL  RELATIONS  OF  X  RAYS  457 

shortly  afterward  repeated  it  on  another  finger,  which  he  covered 
with  some  aluminium  foil  in  such  a  way  as  to  convince  him  that 
the  tissue,  while  still  exposed  to  the  X-ray,  was  shielded  from  the 
brush  discharge.  As  he  obtained  the  same  result,  he  concluded 
in  favor  of  the  Rontgen  ray  itself.  In  a  recent  article  on  the  sub- 
ject he  shows  that  this  effect  is  due  to  those  of  the  rays  that  are  less 
readily  transmitted  by  the  tissues  and  are  less  valuable  for  skia- 
graphic  purposes. 

This  quotation  is  made  not  only  from  its  value  as  an  experiment, 
but  also  because  it  is  so  clear  a  description  of  this  form  of  derma- 
titis. The  long  period  before  the  effects  become  evident  is  quite 
characteristic,  although  in  many  cases  they  have  appeared  sooner. 
It  seems  probable  that  the  direct  effect  is  on  the  vasomotor  or 
trophic  nerve  supply,  which  eventually  affects  the  nutrition  of 
the  part. 

This  chapter  has  been  mainly  devoted  to  warnings  of  the  dan- 
gers of  the  Rontgen  ray,  and  may  in  a  measure  discourage  prac- 
titioners from  its  use.  It  should  be  stated,  however,  that  when 
the  limits  of  error  are  kept  clearly  in  mind,  the  actual  value  of  the 
discovery  to  surgical  science  is  very  great.  When  there  is  doubt  of 
the  diagnosis  of  a  fracture,  no  physician  has  done  his  full  duty  by 
his  patient  if  he  can  command  skiagraphic  examination  and  has 
not  used  it.  This  is  particularly  true  in  medicolegal  cases  where 
there  is  a  question  of  liability. 


Conclusions  Expressing  the  Views  of  the  American  Sur- 
gical Association  upon  the  Medicolegal  Relations  of 
X-rays;  Adopted  in  May,   1900. 

I.  The  routine  employment  of  the  X-ray  in  cases  of  fracture  is 
not  at  present  (1900)  of  sufficient  definite  advantage  to  justify  the 
teaching  that  it  should  be  used  in  every  case.  If  the  surgeon  is  in 
doubt  as  to  his  diagnosis,  he  should  make  use  of  this  as  of  every 
other  available  means  to  add  to  his  knowledge  of  the  case,  but 
even  then  he  should  not  forget  the  grave  possibilities  of  misinter- 
pretation. There  is  evidence  that  in  competent  hands  plates  may 
be  made  that  will  fail  to  reveal  the  presence  of  existing  fractures  or 
will  appear  to  show  a  fracture  that  does  not  exist. 


45^      THE    ROXTGEX    RAV    AXD    ITS    RELATION    TO    FRACTrRES 

2.  In  the  regions  of  the  base  of  the  skull,  the  spine,  the  pelvis, 
and  the  hips,  the  X  ra\-  results  have  not  as  vet  been  thoroughly 
satisfactory,  although  good  skiagraphs  have  been  made  of  lesions 
in  the  last  three  localities.  On  account  of  the  rarity  of  such  skia-* 
graphs  of  these  parts,  special  caution  should  be  observed,  when 
they  are  affected,  in  basing  u])on  X-ray  testimony  any  important 
diagnosis  or  line  of  treatment. 

3.  As  to  questions  of  deformity,  skiagraphs  alone,  without  ex- 
pert surgical  interpretation,  are  generally  useless  and  frequently 
misleading.  The  appearance  of  deformity  may  be  produced  in 
any  normal  bone,  and  existing  deformity  may  be  grossly  exag- 
gerated. 

4.  It  is  not  possible  to  distinguish  after  recent  fractures  between 
cases  in  which  perfectly  satisfactory  callus  has  formed  and  cases 
which  will  go  on  to  nonunion.  Xeither  can  fibrous  union  be  dis- 
tinguished from  union  by  callus  in  which  lime-salts  have  not  yet 
been  deposited.  There  is  abundant  evidence  to  show  that  the  use 
of  the  X-ray  in  these  cases  should  be  regarded  as  merely  the  ad- 
junct to  other  surgical  methods,  and  that  its  testimony  is  espe- 
cially fallible. 

5.  The  evidence  as  to  X-ray  burns  seems  to  show  that  in  the 
majority  of  cases  they  are  easily  and  certainly  preventable.  The 
essential  cause  is  still  a  matter  of  dispute.  It  seems  not  unlikely, 
when  the  strange  susceptibilities  due  to  idiosyncrasy  are  remem- 
bered, that  in  a  small  number  of  cases  it  may  make  a  given  in- 
dividual especially  liable  to  this  form  of  injury. 

6.  In  the  recognition  of  foreign  bodies  the  skiagraph  is  of  the 
very  greatest  value ;  in  their  localization  it  has  occasionallv  failed. 
The  mistakes  recorded  in  the  former  case  should  easily  have  been 
avoided ;  in  the  latter,  they  are  becoming  less  and  less  frequent, 
and  by  the  employment  of  accurate  mathematical  methods  can 
probably  in  time  be  eliminated.  In  the  mean  while,  however,  the 
surgeon  who  bases  an  important  operation  on  the  localization  of  a 
foreign  body  buried  in  the  tissues  should  remember  the  possibility 
of  error  that  still  exists. 

7.  It  has  not  seemed  worth  while  to  attempt  a  review  of  the 
situation  from  the  strictly  legal  standpoint.  It  would  vary  in 
different  vStates  and  with  different  judges  to  interpret  the  law. 


MEDICOLEGAL    RELATIONS    OF    X-RAYS  459 

The  evidence  shows,  however,  that  in  many  places  and  under 
many  differing  circumstances  the  skiagraph  wiU  undoubtedly  be 
a  factor  in  medicolegal  cases. 

8.  The  technicalities  of  its  production,  the  manipulation  of  the 
apparatus,  etc.,  are  already  in  the  hands  of  specialists,  and  with 
that  subject  also  it  has  not  seemed  worth  while  to  deal.  But  it  is 
earnestly  recommended  that  the  surgeon  should  so  familiarize 
himself  with  the  appearance  of  skiagraphs,  with  their  distortions, 
with  the  relative  values  of  their  shadows  and  outlines,  as  to  be 
himself  the  judge  of  their  teachings,  and  not  to  depend  upon  the 
interpretation  of  others,  who  may  lack  the  wide  experience  with 
surgical  injury  and  disease  necessary  for  the  correct  reading  of 
these  pictures. 


CHAPTER  XIX 
THE  EMPLOYMENT  OF  PLASTER-OF-PARIS 

Many  fractures  of  the  upper  and  lower  extremities  may,  at  some 
period,  very  properly  be  treated  by  the  plaster-of- Paris  splint. 

The  plaster-of- Paris  should  be  of  the  best  quality  and  dry. 
Crinoline  is  used  for  bandages.  Commercially  it  is  called  Arrow- 
wanna  Crinoline  Lining.  It  is  a  lining  material  that  is  coarser 
meshed  than  the  cheese-cloth  used  for  gauze  bandages,  and  is  also 
stiffer  than  cheese-cloth.  It  should  be  cut  into  four-yard  lengths, 
folded,  and  stitched  together.  Crinoline  contains  considerable 
sizing  or  glue.  This  is  detrimental  to  its  use  as  a  plaster  bandage. 
It  should,  therefore,  be  washed  of  the  sizing  in  lukewarm  water, 
thoroughly  rinsed,  and  rough  dried.  The  stitching  holds  the 
material  firmly  together  during  the  washing.  It  should  then  be 
cut  into  strips  the  widths  of  the  desired  bandages.  Three  widths 
are  ordinarily  useful — namely,  widths  of  two  inches,  three  inches, 
and  five  and  one-half  inches.  These  four-yard  strips  are  made 
into  roller  bandages.  A  fine-meshed  gauze  bandage  is  being  used 
quite  commonly  in  place  of  crinoline. 

Rolling  the  Plaster. — It  is  a  simple  matter  to  make  one's  own 
plaster  roller  bandages.  It  is  possible  to  purchase  plaster  ban- 
flages  in  sealed  packages.  These  are  ordinarily  made  with  un- 
washed crinoline  and  are  less  desirable.  A  shallow  box  or  tray  is 
needed  to  hold  the  plaster.  Two  persons  can  roll  the  bandage 
with  facility.  "A"  manages  the  roll  of  crinoline,  straightens  it  as 
it  unwinds,  spreads  the  plaster  with  a  light  piece  of  board,  the  size 
of  the  hand,  while  "B"  draws  the  crinoline  across  the  tray  from 
under  the  board  held  by  "A,"  and  rolls  up  the  bandage  loosely 
and  evenly.  "A"  with  the  board  held  still  and  plaster  heaped 
upon  the  bandage  behind  it,  regulates,  by  more  or  less  pressure 
upon  the  bandage,   the  amount  of  plaster  distributed  over  the 

crinoline.      It  requires  but  ten  or  fifteen  minutes  to  make  enough, 

460 


461 


=  a  ? 


-     V     ^ 
J=    o 


a,  V 


MAKING    THE    PLASTER    BANDAGE 


463 


bandages  for  a  plaster  splint  for  the  leg  or  thigh.  An  advantage 
in  making  one's  own  bandages  is  that  they  are  made  of  the  desired 
width  and  have  the  proper  amount  of  plaster.  They  are  fresh 
and  more  likely,  therefore,  to  set  readily  upon  being  wet.  If 
many  bandages  are  made  at  a  time  they  may  be  kept  in  a  tin 
cracker  box.     If  the  closed  box  is  put  in  a  dry  place,  these  ban- 


Fig.  615. — Fracture  of  the  elbow  or  forearm.    Application  of  sheet  wadding  for  protection. 
Method  of  holding  the  arm  at  a  riarht  angle. 


dages  will  keep  indefinitely.  Should  the  plaster  become  damp,  the 
bandages  should  be  placed  in  a  warm  oven  until  dry.  It  is  im- 
portant in  making  the  plaster  rollers  to  put  just  enough  plaster 
into  the  bandage  and  to  distribute  the  plaster  evenly  through  the 
meshes  of  the  crinoline.  The  proper  amount  of  plaster  to  put  into 
a  bandage  can  only  be  learned  by  experience  in  making  and  using 
the  bandages.     It  is  a  common  error  to  spread  the  plaster  too 


464 


THE    EMPLOVMEXT    OF    PLASTER-OF-PARIS 


thicklv.  The  water  in  which  the  bandages  arc  dipped  should  be 
lukewarm  and  of  sulTicienl  depth  to  cover  the  bandages  when  set 
up  on  end.  The  water  working  its  wav  into  the  meshes  of  the 
bandages  displaces  the  air  in  the  bandage,  which  is  indicated  bv 
the  bubbles  rising  to  the  surface  of  the  water.  As  soon  as  the 
bubbles  have  stopped  rising  the  plaster  is  thoroughly  wet  through- 
out the  bandage.     Table  salt,  two  teaspoonfuls  to  four  quarts  of 


Fig.  616. — Fracture  of  the  elbow  or  forearm.     Application  of  plaster-of-Paris  bandage. 
Method  of  holding  the  arm. 


water,  hastens  the  setting  of  the  plaster.  Its  use,  however,  is  to  be 
deprecated,  because  the  plaster  has  to  be  applied  too  quickly  for 
the  best  results  in  plaster  work,  and  the  brittleness  of  the  plaster 
resulting  from  the  use  of  salt  is  undesirable.  The  plaster  bandage 
should  be  lifted  from  the  water  carefully  with  both  hands  holding 
the  two  ends  so  as  to  retain  as  much  plaster  as  possible  within  the 
roll.     The  bandage  should  then  be  wrung  free  from  water  while 


Fig.  617. — Fracture  of  the  elbow  or  forearm.     Plaster-of-Paris  splint  being  applied. 

at  a  right  angle. 


Elbow 


Fig.  618. — Anterior  and  posterior  splints  being  applied  after  having  become  firm  upon  the 
forearm.     For  fracture  of  forearm  bones. 


30 


465 


Fig.  619. — Anterior  and  posterior  splints  in  position.     To  be  held  in  place  by  adhesive-plaster 
strips  and  a  bandage.     A  light,  durable,  cheap,  efficient  splint. 


Fig.  620. — A  posterior  splint  for  elbow,  forearm,  and  upper  arm.     It  is  most  comfortable. 

466 


Fig.  621. — Posterior  elbow  splint  in  position. 


Fig.  622. — Posterior  and  anterior  splints  for  elbow.    Anterior  splint  being  applied. 


467 


Fig.  623. — Anterior  and  posterior  splints  for  the  elbow.     Note  the  additional  plaster  wedge 
being  put  in  place  to  strengthen  the  anterior  splint  at  the  bend  of  the  elbow. 


Fig.  624. — Anterior  and  posterior  plaster  splints  applied.     Most  comfortable  and  efficient  in 
injuries  high  up  the  forearm  and  at  the  elbow  and  lower  part  of  upper  arm. 

468 


Fig.  625. — Lateral  or  side  splint  of  plaster-of-Paris  for  the  foot,  ankle,  and  lower  leg. 
Note  shape  of  crinoline.  The  plaster  cream  is  being  poured  from  pitcher  and  evenly  rubbed 
into  the  layers  of  crinoline. 


Foot  Portion, 


Fig.  626. — Lateral  or  side  splint  of  plaster-of-Paris  ready  for  application  to  leg,  ankle,  and  foot. 
Plaster  cream  has  been  thoroughly  rubbed  into  the  meshes  of  the  crinoline. 


469 


Fig.  627.— Lateral  or  side  splint  of  plaster-of-Paris  applied  to  the  inner  side  of  leg,  ankle, 
and  foot.  Held  in  position  ready  for  bandage.  Note  the  perforated  tin  strip  at  the  ankle 
for  greater  strength.     Foot  at  right  angle  with  leg. 


Fig.  628.— Lateral  or  side  splint  of  plaster-of-Paris.     Retentive  bandage  being  applied.     Tin 
reinforcing  strip  seen  at  the  ankle. 


470 


Fig.  629. — P4aster  gutter  to  posterior  surface  of  leg  and  foot,  held  in  place  by  a  few  turns 
of  a  cheese-cloth  bandage.  This  plaster  posterior  splint  is  made  much  as  is  the  lateral  plaster 
splint  for  the  leg  and  foot. 


Fig.  630. — Anterior  and  posterior  plaster  splints  for  injuries  to  the  leg  below  the  knee  and 
about  the  ankle  and  foot.     Anterior  splint  being  applied. 


471 


Fig.  631. — Anterior  and  posterior  leg  splints  applied.     Note   application  of  the  half  cuff  of 
plaster  to  reinforce  the  ankle. 


Fig.  632. — Fracture  of  the  patella.     The  leg  covered  with  sheet  wadding.     The  application 
of  the  plaster-of-Paris  roller. 


472 


Fig.  633.- 


-Fracture  of  the  patella.    Application  of  the  plaster-of-Paris  roller, 
finished. 


Bandage  being 


Fig.  634. — Fracture  of  the  leg.     Plaster-of-Paris  splint  applied  from  the  toes  to  the  groin. 
Foot  at  a  right  angle  with  the  leg.     Toes  padded  to  prevent  chafing. 


473 


Fig.  635. — Fracture  of  the  leg.     Plaster  cast  of  leg  from  toes  to  below  the  knee  removed. 


Fig.  636. — Fracture  of  the  leg.     Removable  plaster  cast  of  leg.     Same  as  figure  635 
vievi',  showing  cut  in  plaster. 

474 


Fig.  637. — Open  fracture  of  the  leg.     Plaster-of-Paris  splint.     Window  cut  in  plaster,  through 
which  wound  is  dressed.     Window  surrounded  by  oiled  silk. 


Fig.  638. — Open  fracture  of    the  ankle.     Window  in  plaster-of-Paris  splint,  through  which 
wound  is  dressed.     Gauze  seen  in  the  window.     Oiled  silk  about  the  window. 


475 


476 


THE    liMPUOVMENT    OF    PLASTEROF-PARIS 


the  hands  still  grasp  its  ends.  The  bandage  shonld  be  wrung  until 
it  does  not  drip.  In  the  a])plieation  of  the  plaster  splint  to  frac- 
tures of  any  part  of  the  body  it  is  important  that  all  deformity 
should  be  corrected  and  that  the  part  should  be  thoroughly  im- 


p's- 639. — Ham  splint  of  plaster-of-Paris.  The  spliiil  is  slightly  thicker  at  tlie  ham 
underneath  the  region  touched  by  the  thumb  in  the  plate.  It  is  thus  strengthened.  More 
comfortable  than  ordinary  wooden  ham  splint. 


mobilized.     This  necessitates  the  presence  of  one  or  two  assist- 
ants. 

In  applying  a  plaster  splint  with  the  roller  bandage  the  surgeon 
should  do  his  work  so  carefully  that  he  scatters  no  plaster  any- 
where but  upon  the  splint  and  in  the  pail  of  water.  The  surgeon 
should  work  neatly.  The  patient  should  be  protected  by  a  sheet. 
The  floor  should  be  protected  by  a  sheet  spread  under  the  patient 
and  under  the  chair  of  the  surgeon.     The  surgeon  should  remove 


APPIyYING    THE    PLASTUR    BANDAGE; 


477 


his  coat,  roll  up  his  sleeves,  and  be  protected  from  unexpected 
spattering  of  plaster  by  an  apron  or  sheet  over  his  body. 

One  thickness  of  sheet  wadding  torn  into  strips,  from  three  to 
five  inches  wide,  and  rolled  into  roller  bandages  and  then  applied 
to  the  limb  forms  the  best  protection  to  the  skin  in  applying  the 
plaster  splint.  The  sheet  wadding  is  purchased  at  any  of  the  dry- 
goods  stores.  It  may  be  purchased  by  the  quarter  bale  or  by  the 
single  sheet.  The  plaster  bandage  should  be  applied  to  the  pro- 
tected part  slowly,  deliberately,  and  accurately.     The  bandage 


Fig.  640. — Fracture  of  the  patella.     Leather  knee-cap  with   hooks  for  lacing.     Made   from 
plaster  cast.     Worn  as  a  protection  to  knee  after  fracture. 


should  be  applied  smoothly,  and  should  have  no  wrinkles  or  thick 
awkward  places  anywhere.  It  is  well  to  rub  the  bandage  as  fast  as 
it  is  laid  upon  the  part  with  the  palm  of  the  hand  slightly  wet  to 
distribute  the  plaster  cream  thoroughly  and  evenly.  Over  bony 
prominences  the  bandage  should  be  very  carefully  molded.  This 
will  insure  a  good  fit  and  less  likelihood  of  slipping  upon  change  of 
position.  It  is  well  to  carry  the  first  roll  of  plaster  as  far  as  it  will 
go,  one  or  two  layers  thick,  completing  the  whole  splint  once,  and 
then  to  go  over  it  again  from  beginning  to  end.  A  sufficient  num- 
ber of  layers  should  be  applied  to  make  a  firm  enough  splint  for  the 


478 


THE    EMPLOYMENT    OF    Pl.ASTIvR'Ol'-I'ARIS 


support  of  the  part  when  the  plaster  has  set.  The  sphnt  should 
be  as  light  as  is  compatible  with  strength.  Light  splints,  if  accu- 
rately fitted,  accomplish  more  good  than  heavy,  ill-fitting  ones. 
It  is  better  to  use  too  few  rolls  of  plaster  bandage  rather  than  so 
many  that  a  heavy  and  cumbersome  splint  is  made.  Immediately 
after  the  plaster  has  set,  if  it  is  found  to  be  too  weak  at  any  spot, 
an  additional  bandage  mav  be  used  to  reinforce  at  that  point. 
The  part  bandaged  should  be  held  in  perfect  position  until  the 
plaster  has  set  firmly  enough  to  support  it.     This  will  ordinarily 


Fig.  641. — Fracture  of  the  leg.     Removable 
dextrin  splint  with  hooks  and  lacing. 


Fig.  642. — Fracture  of  the  leg.    Same  as 
figure  641.     Anterior  view. 


occur  in  about  ten  or  fifteen  minutes.  The  weight  of  the  splint 
may  be  materially  reduced  by  using  tin  strips  incorporated  in  the 
lavers  of  the  plaster  bandage.  These  strips  should  be  perforated 
bv  holes  so  as  to  offer  rough  places  to  catch  in  the  plaster  bandage. 
The  two  ends  of  the  splint  should  be  so  finished  that  pressure  and 
consequent  deformity  can  not  occur — for  instance,  the  plaster  of 
the  forearm  should  stop  just  short  of  the  bend  of  the  elbow.  The 
plaster  of  the  thigh  should  be  so  far  below  the  perineum  and  groin 
as  to  permit  of  flexion  of  the  thigh  upon  the  trunk  without  ex- 


the;  dextrin  bandage;  479 

coriating  the  skin  of  the  groin.  The  toes  and  fingers  should  be 
left  uncovered  to  admit  of  inspection. 

A  certain  degree  of  skill  is  demanded  upon  the  part  of  the  sur- 
geon for  the  proper  application  of  the  plaster-of- Paris  splint. 
Plaster-of- Paris,  when  used  for  fractured  bones,  is  applied  either 
before  or  after  the  swelling  has  taken  place:  if  applied  before,  it 
constricts  the  seat  of  fracture,  prevents  swelling,  and  may  cause 
great  pain ;  if  applied  after  the  swelling  has  taken  place,  it  becomes 
loose  as  soon  as  the  swelling  of  the  soft  parts  subsides,  and  motion 
of  the  limb  in  the  splint  and  of  the  fragments  of  the  fractured  bone 
one  upon  the  other  is  possible.  It  is  important,  therefore,  to  split 
the  plaster  soon  after  it  has  been  applied,  and  thus  obviate  these 
dangers  of  too  light  and  too  loose  a  splint.  The  tightness  of  the 
splint  should  be  regulated  by  straps  and  a  bandage  of  cheese-cloth. 

The  Removal  of  the  Plaster  Splint.~The  removal  of  the  plaster 
splint  is  difficult.  No  instrument  has  been  devised  that  is  more 
efficient  than  an  ordinary  sharp  jack-knife.  If  the  plaster  splint 
is  split  immediately  after  its  application, — i.  e.,  as  soon  as  it  is 
hard, — it  will  be  far  easier  than  if  it  is  cut  after  it  is  thoroughly 
dry.  A  strip  of  tin  an  inch  wide  laid  upon  the  protected  leg  and 
covered  by  the  plaster  in  its  application  will  often  be  of  great  ser- 
vice upon  removing  the  plaster.  The  tin  will  serve  as  a  protection 
to  the  skin,  and  the  cutting  may  be  done  more  quickly  and  easily. 

After  removing  most  of  the  plaster  from  his  hands  the  surgeon 
should  wash  his  hands  with  a  little  water  and  granulated  sugar  or 
molasses.  The  sugar  assists  in  removing  all  traces  of  plaster  and 
leaves  the  skin  soft  and  clean.  Bandages  of  plaster-of- Paris  are  so 
readily  obtained,  so  efficient,  so  safe  from  interference  upon  the 
part  of  the  patient,  and  so  easy  to  apply,  that  it  is  surprising  they 
are  not  applied  more  often  than  they  are. 

The  dextrin  bandage  is  much  slower  in  becoming  firm  than  the 
plaster  bandage,  and  yet  is  very  light  and  serviceable.  It  is  ap- 
plied exactly  as  is  the  plaster-of- Paris  bandage.  The  roller  ban- 
dage of  cotton  cloth  is  first  unrolled  and  rerolled  in  a  basin  contain- 
ing a  watery  solution  of  powdered  dextrin.  Formula  for  making 
the  solution  of  dextrin:  Add  about  fourteen  ounces  of  powdered 
dextrin  to  a  pint  of  water,  boil  until  dissolved,  strain,  and  add 
one  ounce   of  alcohol.     The   bandage  is,    therefore,    thoroughly 


4So  THE    EMPLOYMENT    OF    PLASTER-OF-PARIS 

saturated  with  llie  dextrin  solution.  After  covering  the  part 
bandaged  once,  dextrin  is  painted,  with  a  small  paint-brush,  over 
the  bandage.  This  is  allowed  to  dry  before  a  second  and  a  third 
layer  of  the  bandage  are  applied.  After  each  bandage  a  coating  of 
dextrin  is  ap])lie(l.  After  the  final  bandage  several  coatings  of 
dextrin  arc  applied,  until  a  shiny,  smooth  surface  results.  This 
bandage  mav  be  cut,  and,  by  the  addition  of  strips  of  leather  along 
the  cut  edge  upon  which  are  hooks,  may  be  laced  and  unlaced  as 
necessary  (see  Figs.  6i6.  617). 


CHAPTER  XX 
THE  AMBULATORY  TREATMENT  OF  FRACTURES 

By  the  ambulatory  treatment  of  fractures  of  the  lower  extrem- 
ity is  understood  a  method  of  treatment  that  permits  the  im- 
mediate and  continued  use  of  the  injured  limb  as  a  means  of  loco- 
motion. 

Medical  literature  contains  many  references  to  this  method.  It 
has  been  in  use  for  some  ten  years.  It  has  not  met  with  general 
acceptance  even  among  hospital  surgeons.  It  is  a  radical  method 
and  open  to  criticism.  It  contains,  however,  several  important 
suggestions.  It  will  prove  instructive  to  follow  the  adoption  of 
this  method  by  its  advocates,  and  to  discover,  if  possible,  what 
there  is  in  it  of  permanent  value. 

Orthopedic  surgeons  as  early  as  1878  conceived  the  idea  of 
allowing  a  patient  with  a  fracture  of  the  thigh  or  of  the  leg  to  walk 
about  by  means  of  apparatus.  Thomas,  of  Liverpool,  and  Dow- 
browski  used  the  Thomas  knee-splint  in  the  treatment  of  frac- 
tures certainly  as  early  as  the  year  1881  or  1882.  Krause,  a  Ger- 
man surgeon,  published,  in  1 89 1 ,  the  first  account  of  the  treatment 
of  fractures  of  the  bones  of  the  leg  in  walking  patients.  Krause 
demonstrated  that  plaster-of- Paris  could  be  used  as  a  splint  in 
fractures  of  the  leg  and  in  transverse  fractures  of  the  thigh. 
Korsch,  in  1894,  presented  a  paper  to  the  German  Surgical  Con- 
gress demonstrating  that  compound  fractures  of  the  leg  and  frac- 
tures of  the  thigh  may  be  treated  with  plaster-of- Paris  splints  and 
early  use.  Korsch  makes  permanent  extension  in  a  thigh  frac- 
ture, while  traction  is  maintained  by  an  assistant,  by  applying  the 
plaster  directly  to  the  skin,  snugly  to  the  malleoli,  the  dorsum  of 
the  foot,  and  the  heel.  A  padded  ring  is  incorporated  into  the 
upper  limit  of  the  plaster  splint  around  the  thigh,  which  presses 
against  the  tuberosity  of  the  ischium,  and  thus  accomplishes  coun- 

terextension.     Korsch's  cases  were  treated  in  Bardeleben's  clinic. 
31  481 


482  THE    AMBl'I.ATORV    TREATMEXT   OF    FRACTl'RES 

Briins,  of  Tubingen,  in  iSq'^,  described  a  splint  for  ust'  in  these 
cases  of  fracture  of  the  leg  and  thi.<;h.  Dollinger,  of  Budapest,  in 
1893,  described  a  splint  for  the  anabulatory  treatment  of  fractures 
of  both  bones  of  the  leg,  and  reported  three  cases.  Bollinger's 
method  of  applying  the  plaster-of- Paris  splint  is  the  one  generally 
used  whenever  the  ambulatory  treatment  is  employed.  The 
method  is  described  later. 

W'arbasse,  at  the  Methodist  Episcopal  Hospital  of  Brooklyn, 
X.  Y..  in  1893,  was  the  first  in  this  country  to  adopt  systematically 
Bollinger's  method.  Warbasse  reports  six  cases — all  in  young 
adults.  Bardeleben  reported,  in  1894,  one  hundred  and  sixteen 
cases  treated  with  walking  splints.  There  were  eighty-nine  frac- 
tures of  the  leg,  complicated  and  uncomplicated ;  five  fractures  of 
the  patella;  twenty-two  fractures  of  the  thigh,  five  of  which  were 
compound ;  three  cases  of  osteotomy  for  genu  valgum.  Bardele- 
ben lays  down  the  following  law:  "It  is  of  the  greatest  advantage 
to  the  patient  that  such  a  dressing  can  be  applied  to  the  broken  leg 
that  he  can  bear  the  weight  of  the  body  upon  it  and  walk  about ; 
but  such  a  method  of  treatment  should  be  applied  onlv  under 
medical  supervision,  and  with  the  most  careful  consideration  of 
complications  that  might  arise."  Korsch  presented  to  the  Ger- 
man Surgical  Congress,  in  1894,  seven  cases — three  of  the  thigh 
and  four  of  the  leg.  Albers,  in  1 894,  reported  seventy-eight  cases 
(fifty-six  of  the  leg,  five  of  the  patella,  sixteen  of  the  thigh,  and  one 
of  the  leg  and  thigh)  treated  by  the  ambulatory  method.  He 
seems  to  be  a  little  more  cautious  than  other  German  surgeons  in 
this  matter.  He  says  that  when  great  pain  is  present,  it  is  best  to 
employ  injections  of  morphin. 

Elevation  of  the  limb  will  often  reduce  the  swelling;  when  this 
does  not  suffice,  the  bandage  must  be  removed.  Severe  local  pain 
from  pressure  indicates  the  necessity  for  cutting  a  fenestrum.  The 
first  attempt  at  walking  should  be  made  on  the  day  following  the 
application  of  the  cast.  A  crutch  and  cane  are  used  at  first ;  later, 
two  canes  are  employed ;  and,  finally,  some  patients  walk  without 
any  support  at  all.  Krause,  in  1894,  reported  seventy-two  cases 
treated.  He  is  of  the  opinion  that  the  ambulatory  treatment  in 
plaster  splints  must  be  limited  principally  to  fractures  and  osteot- 
omies in  the  region  of  the  malleoli,  the  leg,  and  the  lower  end  of 


the;  method  applied  to  the  tibia  and  vipajla        483 

the  thigh.  He  does  not  employ  the  method  in  the  handhn;^  of 
obHque  fracture  of  the  femur  and  fractures  of  the  neck  of  the 
femur.  Bardeleben  writes  again  in  1895,  reporting  up  to  that  date 
one  hundred  and  eighty-one  cases  treated  by  the  ambulatory 
treatment.  This  last  report,  of  course,  included  the  one  hundred 
and  sixteen  cases  of  the  previous  record.  Dr.  Edwin  Martin,  be- 
fore the  Surgical  Section  of  the  College  of  Physicians  of  Philadel- 
phia, in  December,  1895,  reported  twenty  cases  of  fracture  of  the 
leg  treated  by  this  method.  Dr.  E.  S.  Pilcher,  of  Brooklyn,  N.  Y., 
in  whose  wards  Warbasse  worked,  reported  to  the  American  Sur- 
gical Association  the  twenty  or  more  cases  treated  by  him  in 
which  the  results  were  satisfactory.  N.  P.  Dandridge,  of  Cincin- 
nati, Ohio,  has  used  the  method  in  eight  cases.  In  most  of  the 
cases  pain  was  complained  of  when  weight  was  borne  on  the  foot. 
In  a  feeble  woman  it  was  necessary  to  remove  the  cast  in  the  third 
week.  In  the  case  of  a  man, — a  compound  fracture  of  the  leg, — 
after  walking  two  weeks  he  had  so  much  pain  that  the  plaster  was 
removed.  Redness  and  swelling  were  great  at  the  seat  of  fracture, 
and  there  was  much  swelling  over  the  internal  malleolus.  Wood- 
bury introduced  the  method  at  Roosevelt  Hospital,  New  York 
city,  and  Fiske  has  reported  cases  treated  at  that  clinic.  Roberts, 
of  Philadelphia,  and  Woolsey,  of  New  York,  have  used  the  method 
in  selected  cases  with  satisfaction.  A.  T.  Cabot,  of  Boston,  has 
used,  in  several  fractures  of  the  femur,  Taylor's  long  hip-splint. 
E-  H.  Bradford,  of  Boston,  has  treated  cases  of  fracture  at  the 
Children's  Hospital  by  a  modified  Thomas  knee  splint,  with  and 
without  plaster-of- Paris  splinting  (Fig.  643). 

Those  advocating  the  ambulatory  treatment  suggest  its  appli- 
cation to  fractures  of  the  leg  below  the  knee,  both  simple  and  com- 
pound, and  in  fractures  of  the  lower  end  of  the  femur.  The  appa- 
ratus is  not  to  be  applied  for  three  or  four  days  if  there  is  much 
primary  swelling. 

The  method  of  application  of  the  plaster  splint  in  the  ambu- 
latory treatment  of  fractures  of  the  tibia  and  fibula  alone  is  as 
follows  (this  is  practically  the  method  of  Dollinger) :  First  comes 
the  cleansing  of  the  skin  of  the  leg  with  soap  and  water  and  then 
the  reduction  of  the  fracture.  Then,  with  the  foot  fixed  at  a  right 
angle  to  the  leg,  a  flannel  bandage  is  smoothly  and  evenly  applied 


484 


THE    AMBULATORY    TREATMEXT    OF    FRACTURES 


from  the  toes  to  just  above  the  knee.  This  bandage  is  made  to 
include  beneath  the  sole  of  the  foot  a  padding  of  ten  or  fifteen 
layers  of  cotton  wadding,  making  a  pad  about  three-fourths  of  an 
inch  thick,  after  it  is  compressed  by  the  moderate  pressure  of  the 
flannel  bandage.  Over  this  is  now  ap])lied  the  plaster  bandage 
from  the  base  of  the  toes  to  just  above  the  knee,  especial  care  being 


a.  Ir, 

Fig.  643. — Thomas  knee  splint  or  ambulatory  treatment  of  leg  fractures,  used  with  a  light 
plaster-of-Paris  leg  splint  :  a,  ordinary  form  ;  b,  "  caliper  "  or  convalescent  splint  so  fitted  as 
to  keep  the  heel  of  the  foot  away  from  the  boot  while  the  toes  are  used  ;  c,  the  half-ring 
sometimes  used  at  the  upper  end  ;  d,  lower  end  of  splint,  as  arranged  for  windlass  traction. 


taken  that  the  application  is  made  smoothlv  and  somewhat  more 
firmly  than  is  the  custom  in  the  ordinary  plaster  cast.  The  layers 
of  the  bandage  should  be  well  rubbed  as  they  are  applied,  with  a 
view  to  obtaining  the  greatest  amount  of  firmness  with  the  smallest 
amount  of  material.  The  sole  is  strengthened  by  incorporating 
with  the  circular  turns  an  extra  thickness  composed  of  ten  or 


the;    ADVANTAGISS   CLAIMIiD    F(JR    THE    METHOD  485 

twelve  layers  of  bandage  well  rubbed  together,  and  extending 
longitudinally  along  the  sole.  The  bandage  is  applied  especially 
firmly  about  the  enlarged  upper  end  of  the  tibia,  and  here  it  is 
made  somewhat  thicker.  As  it  dries  it  may  be  pressed  in  so  as  to 
conform  more  closely  to  the  leg  just  below  the  heads  of  the  tibia 
and  fibula.  The  assistant  who  stands  at  the  foot  of  the  table  and 
supports  the  leg  makes  such  traction  or  pressure  as  is  required  to 
keep  the  fragments  in  proper  position  while  the  plaster  is  being 
applied.  The  operation  requires  about  twenty  minutes,  and  by 
the  time  the  last  bandage  is  applied  the  cast  should  be  fairly 
hard. 

It  is  seen  that  when  this  cast  has  become  hardened  the  leg  is 
suspended.  When  the  patient  steps  upon  the  sole  of  the  plaster 
cast,  the  thickness  of  the  cotton  beneath  the  foot  separates  the 
sole  of  the  foot  so  far  from  the  sole  of  the  cast  that  the  foot  hangs 
suspended  in  its  plaster  shoe.  Thus  the  weight  of  the  body, 
which  would  come  upon  the  foot,  is  borne  by  the  diverging  sur- 
face of  the  leg  above  the  ankle.  The  chief  of  these  is  the  strong 
head  of  the  tibia.  A  lesser  role  is  played  by  the  head  of  the  fibula 
and  the  tapering  calf  in  muscular  subjects. 

In  thigh  fractures  the  use  of  the  long  Taylor  hip-splint,  together 
with  a  high  sole  upon  the  well  foot  and  crutches,  is  generally  ac- 
cepted as  the  best  method  of  ambulatory  treatment. 

The  advantages  claimed  for  the  ambulatory  method  are: 

Time  is  saved  to  the  business  man  by  this  method — he  having  to 
give  up  but  about  seven  days  to  a  fracture  of  the  leg.  The  time 
spent  by  the  patient  in  the  hospital  is  less  than  by  other  methods. 
The  general  health  is  conserved;  whereas  by  the  old  method 
the  appetite  is  variable,  sleep  is  troubled,  the  bowels  are  consti- 
pated, and  general  discomfort  prevails.  There  is  greater  general 
comfort  by  this  method  than  by  any  other.  In  drunkards  and 
those  with  a  tendency  to  delirium  tremens  this  liability  is  greatly 
diminished.  In  old  people  the  danger  of  a  hypostatic  pneumonia 
is  lessened.  The  primary  swelling  associated  wdth  a  fracture  is 
often  avoided,  and  always  less  than  by  the  older  methods.  The 
secondary  edema  and  muscular  weakness  are  less.  The  functional 
usefulness  of  the  whole  leg  is  greater.  There  is  less  atrophy  of 
the   muscles  of  the  thigh  and  leg.     The  amount  of  the  callus  is 


486  THE    AMBULATORY    TREATMENT    OF    FRACTURES 

diminished.  There  is  less  stillness  of  neighboring  joints.  Union 
in  a  fracture  occurs  at  an  earhcr  date. 

Before  this  method  can  be  adopted  generally  and  in  hospital 
treatment  it  must  be  demonstrated  that  it  is  safe,  and  that  it 
offers  chances  of  better  functional  results  than  are  obtained  under 
present  methods,  and  that  the  minor  advantages  claimed  for  it  by 
ardent  German  advocates  are  real  and  not  imaginary.  The  first 
great  advantage  of  the  method  is  stated  to  be  that  the  stay  in  the 
hospital  and  the  time  away  from  one's  occupation  are  much  les- 
sened. Regarding  this  point  the  Massachusetts  General  Hospital 
Surgical  Records  were  consulted  for  these  three  periods:  before 
the  use  of  plaster-of- Paris — that  is,  previous  to  1865;  just  at  the 
beginning  of  the  use  of  plaster-of- Paris  as  a  splint  for  fracture,  and 
in  1895,  1896,  and  1897.  Thirty-five  unselected  cases  of  fracture 
of  the  tibia  and  fibula  were  tabulated  from  each  period.  The 
duration  of  the  average  time  spent  in  the  hospital  in  the  first 
period — i.  e.,  previous  to  1865 — was  forty-six  days;  in  the  second 
period — i.  e.,  about  1866 — it  was  forty-five  days;  at  the  present 
time  it  is  sixteen  days.  In  the  second  period  plasters  were  applied 
to  fractured  legs  on  an  average  at  about  the  twenty-eighth  day ;  at 
the  present  time,  on  the  fourteenth  day.  In  other  words,  there 
has  been  since  the  introduction  of  the  plaster  splints  a  gradually 
shorter  detention  in  the  hospital,  as  surgeons  have  come  to  recog- 
nize the  safety  of  an  earlier  application  of  a  fixed  dressing.  On  an 
average,  patients  with  fracture  of  the  leg  are  detained  in  the 
hospital  to-day  but  sixteen  days.  The  very  great  saving  to  the 
hospital  in  time  bv  the  ambulatorv  treatment  does  not,  therefore, 
appear.  It  is  impossible  to  consider  the  statements  made  with 
regard  to  rapidity  of  healing,  sign  of  callus,  absence  of  muscular 
atrophy,  and  absence  of  rigidity  of  joints,  because  there  are  no 
facts  available  for  the  purpose.  The  advantages  stated  are  based, 
most  of  them,  upon  the  personal  impressions  of  the  surgeon  in 
charge ;  impressions  compared  with  scientific  observations  are  un- 
trustworthy. 

Krause  presents  a  table  from  Paul  Bruns  containing  the  average 
periods  of  healing  in  a  series  of  fractures,  and  compares  these 
periods  wath  his  own  fracture  cases  treated  by  the  ambulatory 
method.     This  is  the  only  attempted  scientific  statement  of  obser- 


THE    ADVANTAGES    CLAIMED    FOR   THE    METHOD  487 

vation  on  this  important  point.  Krause  concludes  from  a  study 
of  these  tables  that,  "In  the  treatment  of  fractures  of  the  middle 
and  upper  thirds  of  the  leg,  the  ambulatory  method  shows  a  great 
advantage  in  the  period  of  consolidation  as  well  as  in  the  time 
when  the  patient  can  return  to  work.  It  seems  that  the  higher  up 
the  fracture  is  in  the  leg,  the  sooner  a  cure  is  effected  by  the  am- 
bulatory method  of  treatment." 

Conclusions. — A  review  of  the  literature  does  not  disclose  any 
other  advantage  in  the  results  of  the  ambulatory  treatment  over 
the  present  treatment  of  fractures  of  the  leg  than  that  stated  by 
Krause.  The  present  commonly  accepted  method  of  treating 
fractures  of  the  femur  by  long  rest  in  the  horizontal  position,  with 
extension  by  weight  and  pulley,  is  not  satisfactory.  The  pro- 
tracted stay  in  bed  is  undesirable.  The  use  of  the  Taylor  hip- 
splints  in  the  treatment  of  this  fracture,  assisted  by  coaptation 
splints  or  a  splint  of  plaster-of- Paris,  is  of  distinct  value.  This,  how- 
ever, is  a  somewhat  well-known  method  of  ambulatory  treatment. 

Theoretically  and  practically,  the  ambulatory  treatment  does 
not  perfectly  immobilize;  therefore,  it  can  not  preeminently  suc- 
ceed as  a  means  of  treatment.  The  method  in  general  seems  to 
be  unsurgical.  Embolism,  both  of  fat  and  of  blood,  and  the  likeli- 
hood of  pressure- sores  in  the  use  of  the  plaster  splint  are  dangers  to 
be  considered.  It  is  wise  to  allow  the  injured  limb  to  rest  while 
the  reparative  process  is  beginning.  Muscular  relaxation  is  de- 
sirable in  the  treatment  of  fractures.  The  very  admission  by  the 
advocates  of  the  ambulatory  treatment  that  muscular  contrac- 
tions take  place  is  reason  enough  for  supposing  that  complete 
immobilization  is  not  obtained  by  this  method.  However,  in 
certain  carefully  selected  cases  of  fracture  below  the  knee,  par- 
ticularly of  the  fibula,  if  under  the  care  of  a  competent  and  skilful 
surgeon,  it  is  possible  to  conceive  of  the  ambulatory  method  being 
used  without  doing  harm. 

A  consideration  of  the  ambulatory  treatment  of  fractures 
should  lead  to  a  more  careful  and  early  use  of  the  plaster-of- Paris 
splint  in  fractures  of  the  leg,  and  to  a  proper  application  of  the 
long  hip-splint  or  its  equivalent  in  fractures  of  the  thigh,  and  to 
the  early  use  of  crutches  and  the  high  sole  on  the  well  foot  in  both 
of  these  lesions. 


4s8  the  ambulatory  trkatmext  of  fractures 

Materials  for  the  Ordinary  Care  of  Ceosicd  I'ractures 

The  malerials  willi  which  a  physician  should  he  provided  in 
order  to  properly  care  for  the  fractures  ordinarily  met  with  are 
comparatiYely  few. 

There  is  scarcely  a  fracture  which  can  not  be  treated  satisfac- 
torily by  the  i^rojx'r  use  of  plaster-of- Paris. 

Plaster-of- Paris  roller  bandages. 

Washed  crinoline  or  the  common  cheesecloth  gauze  rollei 
bandage. 

Plaster-of- Paris. 

A  jack-knife  for  splitting  plaster  dressings. 

A  pair  of  heavy  scissors. 

Thin  splint  wood.  -^  of  an  inch  in  thickness. 

Iron  \vire,  j  of  an  inch  in  diameter. 

Posterior  wire  splint,  for  adult  leg. 

Anterior  wire  splint,  for  adult  leg. 

Surgeon's  adhesive  plaster. 

Cotton  and  cheese-cloth  roller  bandages. 

Sheet  wadding  for  padding  splints. 


CHAPTER  XXI 
NOTES  UPON  A  FEW  DISLOCATIONS 

DISLOCATION   OF   THE   CERVICAL   VERTEBRAE 

This  dislocation  may  be  either  bilateral  or  unilateral.  The 
bilateral  form,  in  which  both  the  articular  processes  slip  forward 
or  backward  over  those  below,  is  of  comparatively  infrequent 
occurrence.     It  is  attended  by  marked   symptoms  of  pressure 


Fig.  644. — Dislocation  of  right  articular  process  ;  head  turns  to  left.  Head  also  bent  to 
left  because  process  is  caught.  Left  sternocleidomastoid  relaxed.  Right  sternocleido- 
mastoid tense  and  stretched  (Walton). 


Upon  the  spinal  cord.     A  fatal  termination  is  the  usual  outcome 
of  a  bilateral  dislocation,  although  this  is  not  always  the  case. 

The  most  common  form  of  cervical  dislocation  is  that  occurring 
upon  one  side,  and  is  usually  without  fatal  result.     This  is  rather 


490 


NOTES    UPON    A   FEW   DISLOCATIONS 


a  common  injury.  It  is  often  unrecognized.  In  this  uni- 
lateral dislocation  of  the  cervical  vertebra?  an  articular  process 
slips  over  the  articular  process  below  it  and  either  catches  upon 
the  top  of  the  lower  articular  process  or  slips  down  in  front  of  it. 
This  displacement  causes  the  head  to  tip  over  to  one  side  and 
to  rotate  sidewise.  The  immobility  of  the  head,  the  peculiar 
position  of  the  head,  simulating  a  torticollis;  the  relaxation  of  the 
muscles  of  the  neck — the  contraction  of  which  muscles  would 


Fig.  645.— Right  unilateral  dislocation.     Note  tipping  of  the  head  to  the  left  and  atrophy  of 
the  supraspinatus  and  infraspinatus  muscles  on  the  left  sida (Walton). 


have  produced  the  deformity;  the  taut  condition  of  the  muscles 
upon  the  opposite  side  of  the  neck — these  signs  are  diagnostic  of 
a  dislocation,  of  a  unilateral  dislocation  of  a  cervical  vertebra. 

To  illustrate  definitely :  suppose  that  the  right  articular  process 
slips  forward  and  over  the  corresponding  articular  process  of  the 
vertebrae  below  it  and  has  fallen  into  the  hollow  in  front  of  that 
process.  The  head  will  be  turned  to  the  left  and  will  be  bent 
over  to  the  right,  as  in  figure  647.  The  sternocleidomastoid  will  be 
tense  on  the  left  side  and  lax  on  the  right  side.     Now  suppose,  as 


DISLOCATION    OF    THE    CERVICAL    VERTEBRAE  49 1 


Fig.  646. — Cervical  vertebrse  ;  anterior  surface.     Right  articular  process  of  upper  one  is  dis- 
placed and  caught.     Partial  dislocation.     Clinically  see  figure  644. 


Fig.  647. — Dislocation  of  right  articular  process  ;  ordinary  form,  in  which  the  process  lias 
slipped  way  over ;  head  is  therefore  turned  to  the  left  and  bent  to  the  right ;  the  sternomastoid 
muscle  is  tense  on  the  left,  lax  on  the  right  (Walton). 


Fig.  64S.— Complete  unilateral  right  dislocation.     Head  rigid.     Before  operation.     Process 
has  slipped  way  over  (Beach  ;  Walton). 


Fig.  649.— Unilateral  dislocation.     After  operation.     Head  perfectly  flexible  (Beach  ;  Walton). 


Fig.  650.— Partial  bilateral  cervical  dislocation  ;  anterior  view.     Illustrates  positions  of  bones. 

492 


DISLOCATION    OF    THE    CERVICAL    VERTEBRA  493 

a  second  illustration,  that  there  is  a  dislocation  of  a  right  articular 
process  which  becomes  caught  on  the  top  of  the  articular  prrjcess 
below  it  and  does  not  slip  into  the  hollow  in  front.     The  deformity 


Fig.  651. — Same  as  figure  650.     Lateral  view. 


Fig.  652. — Dislocation  forward  of  sixth  cervical  vertebra.     Total  paralysis  below  nipples. 
Death  eighteen  hours  after  the  accident  (Warren  Museum  Specimen). 


will  be  seen  as  in  figure  644.  The  head  will  turn  to  the  left  as  in 
the  complete  dislocation,  but  the  head  will  be  bent  to  the  left 
because  the  process  is  caught  upon  the  top  of  the  one  below. 


494  NOTES    UPON'    A    Fi:\V    DISLOCATIONS 

Tliis  dislocation  is  oflcii  overlooked  because  of  the  absence  of 
serious  svniptoius  of  ])aralysis. 


Fig-  653.— Fracture-dislocation  of  probably  the  fifth  cervical  or  the  sixth.     Photograph  taken 
several  months  after  the  accident.     No  disability  save  that  due  to  position  of  head. 


Fig.  654.— Lateral  view  of  figure  653.     Head  assumed  this  position  immediately  after  a  fall 

down-stairs. 


Fracture  of  an  articular  process  may  occur  together  with  the 
displacement.     This  is  fortunately  rare. 


DISLOCATION   OF   THK   CERVICAL    VERTEBRA 


495 


The  treatment  of  these  cases  should  be  by  what  Dr.  Walton 
has  demonstrated  and  very  properly  called  retrolateral  flexion 
and  rotation  without  extension.  No  amount  of  extension  will 
unlock  the  dislocation.  The  head  is  to  be  bent  laterally  and 
slightly  backward ;  that  is,  abducted  away  from  the  side  displaced. 
This  will  raise  the  articular  process  out  of  the  notch  into  which 
it  has  fallen.  Then  rotation  of  the  displaced  articular  process 
backward  into  position  will  effect  a  reduction.  This,  of  course, 
is  best  done  under  ether  anesthesia.  It  requires  firm,  even 
manipulation,  but  no  very  great  force. 

The  cases  reported  are  too  few  to  determine  how  long  after  a 


Fig.  655. — Diagram  showing  direction  of  tilting  and  rotating  in  reduction  (Walton). 


dislocation  has  occurred  that  this  procedure  will  prove  efficient. 
Several  cases  are  on  record  in  which  spontaneous  reduction  has  oc- 
curred. If  untreated,  some  of  these  cases  recover  from  the  immo- 
bility and  pain,  so  that  the  disability  is  but  slightly  noticeable. 

Dr.  Walton  writes  as  follows:  "This  diagram  (Fig.  655) 
shows  the  upper  surface  of  the  lower  of  the  two  vertebrae 
concerned,  that  is,  the  one  in  normal  position.  The  articular 
processes  of  this  vertebra  are  marked  xx.  The  left  articular 
process  of  the  vertebra  above  having  slipped  into  the  inter- 
vertebral notch  y,  the  situation  of  its  spinous  process  will 
be  indicated  by  the  dotted  lines.  The  direction  in  which  the 
head  must  be  tilted  for  reduction  is  indicated  by  the  line  z  (in 


496  NOTES    UPON    A    FEW    DISLOCATIONS 

other  words,  if  the  patient  is  facing  north  the  head  must  be  tilted 
southeast) ;  slight  rotation  in  the  direction  of  the  short  curved 
arrow  on  the  right  of  the  diagram  may  be  necessary  to  free  the 
process.  After  the  articular  process  is  freed,  rotation  into  place 
in  the  direction  of  the  long  curved  arrow  on  the  left  of  the  diagram 
will  complete  reduction.  In  case  the  right  articular  process  has  been 
displaced  by  the  dislocation,  these  movements  should  be  reversed." 

In  case  of  bilateral  dislocation  one  process  should  be  freed 
first,  as  in  unilateral  dislocation,  then  the  other. 

Precautions. —  i.  The  patient  should  be  thoroughly  anesthe- 
tized.    This  proceeding  alone  may  produce  the  desired  result. 

2.  The  patient  should  be  placed  upon  a  chair  for  the  operation 
rather  than  upon  a  table,  for  when  the  patient  is  in  the  sitting 
posture  the  operator  not  only  has  more  freedom  of  movement, 
but  is  also  less  likely  to  become  confused  with  regard  to  the 
movements  of  reduction. 

3.  Extension  not  only  does  not  help  reduction,  but  as  Walton 
suggests  may  perhaps  hinder  it  by  lessening  the  effectiveness  of 
the  fulcrum  furnished  by  the  articular  processes  of  the  uninjured 
side.  This  fulcrum  is  essential  to  the  elevation  of  the  displaced 
process  on  the  other  side.  The  head  should  therefore  be  tilted  or 
rocked  without  traction. 

DISLOCATION  OF  THE  JAW 

The  common  dislocation  is  of  the  inferior  maxilla  forward.  It 
is  ordinarily  a  bilateral  dislocation.  The  condyles  of  the  lower 
jaw  slide  forward  and  over  the  articular  eminence  of  the  temporal 
bone.     There  is  usually  no  rupture  of  the  capsular  ligament. 

The  appearances  of  such  a  dislocation  are  well  shown  in  figures 
658  and  659.  The  mouth  is  open;  the  inferior  maxilla  is  fixed 
and  is  forward  of  its  usual  place;  the  masseter  and  temporal 
muscles  are  stretched  and  taut ;  the  normal  hollow  of  the  glenoid 
cavity  can  be  felt  in  front  of  the  ear — ordinarily  this  is  filled  by 
the  articular  process  of  the  lower  jaw.  If  only  one  side  is  dislo- 
cated, the  chin  will  be  pushed  over  to  the  opposite  side  from  the 
dislocation  and  the  signs  will  be  unilateral. 

Reduction    occasionally    occurs    spontaneously.     In    order    to 


DISLOCATION    OF    THE    JAW 


497 


effect  reduction  easily,  it  is  necessary  to  relax  the  lateral  ligament 
of  the  joint.  The  manocuver  of  reduction  is  best  carried  out  with 
the  aid  of  general  anesthesia.     In  order  to  relax  the  lateral  liga- 


Fig.  656.— Note  the  normal  relations  of  the  condyle  to  the  glenoid  ;  the  interarticular  car- 
tilage (after  Helferich). 


Fig.  657.— Double  dislocation.     Note  open  mouth  ;  displaced  articular  process  ;  empty 
glenoid.     Capsule  uninjured  ;  temporal  muscle  taut  (after  Helferich). 


ment,  the  mouth  should  be  still  further  opened  by  pressure  upon 
the  incisor  teeth;  that  is,  by  depressing  the  chin.     Having  thus 
somewhat  relaxed  the  lateral  ligament,  direct  pressure  backward 
will  effect  a  reduction. 
32 


498  NOTES    UPON    A    I-EW    DISLOCATIONS 


Fig.  658.— Bilateral  anterior  dislocation  of  the  lower  jaw.    Note  depressed  chin,  rigid  lower 
jaw,  open  mouth,  drawn  cheeks  (Massachusetts  General  Hospital). 


Fig.  659.— Lateral  view,  same  case  as  figure  65S.    Note  rigidity  of  lower  jaw  muscles.    Neck 
held  stiffly  (Massachusetts  General  Hospital). 


DISLOCATION    OF    THE   JAW 


499 


The  more  common  and  older  method  used  for  reducing  this 
dislocation  is  by  pressing  down  upon  the  molar  teeth  and  lifting 
and  pressing  back  the  chin.  This  method  is  usually  not  so  satis- 
factory as  is  that  first  described. 

Recurring  dislocations  can  be  successfully  treated  by  open 
incision  and  suturing  the  meniscus  to  the  periosteum  of  the  bone. 


Fig.  660. — Fracture  of  the  inferior  maxilla  mistaken  for  a  unilateral  dislocation.     Note 
deviation  of  the  chin  to  the  left  side. 


Simple  immobilization  of  a  reduced  dislocation  for  a  period  of  a 
few  weeks  will  often  prevent  recurrence  of  the  difficulty. 

Old  irreducible  dislocations  may  require  resection  of  the  con- 
dyles of  the  lower  jaw,  or  it  may  be  possible  to  reduce  the  dislo- 
cation by  the  method  of  McGraw.  McGraw's  method  consists 
in  making  a  tiny  incision  through  the  skin  over  the  neck  of  the 
inferior  maxilla  and  inserting  through  it  a  steel  hook,  which  is 
usually  so  bent  as  to  fit  accurately  the  neck  of  the  jaw.  Traction 
upon  this  hook  will  sometimes  reduce  the  dislocation. 


500 


NOTES    UPON    A    FEW    DISLOCATIONS 


DISLOCATION  OF  THE  CLAVICLE 


Outer 
cud  of 
clavicle. 


I'it;.  66i. — Acromioclavicular  dislocation.  Dislocation  of  the  outer  end  of  left  clavicle 
upward.  Complete  form.  Disability  of  upperarm,  certain  movements  painful.  Treatment  of 
this  dislocation  is  often  successful  by  pressure  applied  after  reduction,  as  shown  under  frac- 
ture of  clavicle.  Open  incision  and  suture  are  indicated  if  reduction  is  impossible  and  dis- 
abilitv  exists. 


Outer  end  of  clavicle. 


Fig.  662. — I'pward  dislucation  of  the  cla\icle  at  the  left  acromioclavicular  joint. 


DISLOCATION    OF    THE    SHOULDER 


501 


DISLOCATION  OF  THE  SHOULDER 

The  head  of  the  humerus,  through  extreme  abduction  of  the 
arm,  leaves  the  capsule  of  the  shoulder-joint  at  its  lowest  point. 
The  upper  end  of  the  humerus  rests  beneath  the  coracoid  process 
in  the  common  form  of  dislocation  of  the  shoulder. 

The  signs  of  a  subcoracoid  dislocation  are  partly  illustrated  in 
the  chapter  on  Fracture  of  Humerus.   The  direction  of  the  long  axis 


Zl.CU^i'~Zje^ 


fci.  OtO(rvK.^jr>\. 


iO-Ct  4^  nA 


nA^'^^SMM*' 


Fig.  663. — X-ray  of  a  subcoracoid  dislocation  of  the  humerus.  Note  the  position  of  the 
humeral  head,  with  reference  to  acromion,  coracoid,  clavicle,  and  glenoid  cavity.  (X-ray 
taken  by  Mr.  Dodd,  Massachusetts  General  Hospital. 


of  the  upper  arm  is  changed  from  the  normal.  The  arm  is  per- 
manently abducted  from  the  body.  Voluntary  movements  of  the 
shoulder  are  more  or  less  restricted.  The  shoulder  is  flattened  be- 
cause the  head  of  the  humerus  is  absent  from  its  normal  position. 
The  head  of  the  bone  is  felt  in  its  new  position  under  the  coracoid 
process.  The  head  of  the  bone  may  be  fairly  easily  felt  by  pal- 
pating the  axilla.  The  elbow  cannot  be  brought  readily  to  the  side. 
Before  any  attempt  is  made  at  reducing  the  dislocation  it  is 
wise  to  determine  so  far  as  possible,  by  careful  examination  and 


502 


NOTES   UPON    A   FEW   DISLOCATIONS 


Fig.  664.— Subcoracoid  dislocation  01  the  left  sliouldei .  Note  change  in  axis  of  humerus. 
Note  method  of  palpating  under  acromion,  demonstrating  hollow  on  the  left  due  to  absence  of 
head  of  bone  from  the  glenoid  cavity. 


Fig.  665.— Dislocation  of  the  humerus.     Note  muscles  of  shoulder,  flattened  deltoid.     Note 
position  of  the  head  of  the  humerus  (after  Helferich). 


DISLOCATION    OK    THE)    SHOULDIiR 


503 


by  the  assistance  of  the  X-ray,  whether  or  nfjt  a  fracture  of  the 
anatomical  or  surgical  neck  or  the  tuberosity  of  the  humerus  or 
of  the  glenoid  cavity  of  the  scapula  has  occurred,  complicating 
the  dislocation.     Obviously,  if  a  fracture  exists  associated  with 


Fig.  666. — Reduction  of  subcoracoid  dislocation  of  tiie  shoulder.  First  position :  Elbow 
at  side,  forearm  rotated  outward.  Note  fulness  (head  of  humerus)  beneath  coracoid  pro- 
cess (»z)  !  absence  of  head  of  humerus  under  acromion  (/);  relaxed  muscles  (^,  h,  J), 
a,  Deltoid;  d,  pectoralis  major;  c,  pectoralis  minor;  d,  coracobrachialis ;  e,  biceps,  two 
heads;  _f,  triceps;  £:,  supraspinatus ;  h,  subscapularis ;  /,  subscapularis ;  k,  humerus; 
/,  acromion  process;  m,  coracoid  process;  n,  coracoacromial  ligament. 


a  dislocation,  it  will  most  likely  be  impossible  to  effect  the  reduc- 
tion by  manipulation. 

The  older  method  of  reduction  is  still  often  useful.     By  the 
older  method  traction  is  made  upon  the  humerus,  which  is  grasped 


504 


NOTES    UPON    A    FHW    DISLOCATIONS 


at  the  elbow,  with  the  arm  raised  to  a  right  angle  with  the  body. 
Countertraction  is  made  by  steadying  the  trunk  by  means  of  a 
folded  sheet  around  the  chest.  While  traction  is  being  made, 
the  arm  is  gradually  brought  lo  the  side.  A  third  assistant 
manipulates  by  pressure  the  head  of  the  bone  wliik-  the  traction 
is  being  made. 

The  best  method  for  the  reduction  of  the  common  subcoracoid 
shoulder  dislocation  is  that  known  as  Kocher's  method.  It  con- 
sists of  the  following  procedures: 


Fig.  667. — Reducing  dislocation  of  the  shoulder.  Note  shoulder  over  edge  of  table; 
patient  on  back.  First  step:  Elbow  at  side.  Note  method  of  grasping  above  elbow  and 
wrist. 


1.  A\'ith  the  patient  lying  upon  the  back,  the  surgeon,  standing 
upon  the  side  of  the  dislocated  shoulder,  grasps  with  one  hand  the 
dislocated  humerus  above  the  condyles,  and  with  the  other  hand 
the  wrist  of  the  patient.  The  forearm  of  the  patient  is  flexed  at 
a  right  angle.  The  elbow  is  carried  well  to  the  side  of  the  body. 
See  figures  666  and  667. 

2.  See  figures  668  and  66y.  The  humerus  is  rotated  upon  its 
long  axis,  carrying  the  forearm  outward,  external  rotation.  This 
movement  is  an  important  one,  as  by  it  the  opening  in  the  capsule 


DISLOCATION    OF    THF.    SHOULDER 


505 


through  which  the  head  of  the  bone  left  the  joint  is  relaxed  and 
made  patent. 

3.  See  figures  670  and  671.  With  the  humerus  thus  rotated 
strongly  outward,  the  elbow  is  strongly  adducted  just  across  the 
median  line  of  the  body. 


Fig.  668. — Reduction  of  subcoracoid  dislocation  of  the  shoulder.  Second  position :  Fore- 
arm held  rotated  outward.  Elbow  advanced  across  the  thorax  to  near  median  line.  Trac- 
tion downward  in  line  of  long  axis  of  humerus.     (Lettering  same  as  in  Fig.  666.) 


4.  See  figures  672  and  673.  When  the  elbow  is  brought  well 
to  the  median  line  in  adduction,  the  hand  is  placed  upon  the 
opposite  shoulder,  thus  rotating  the  humerus  inward. 

Throughout  these  four  procedures  good  steady  traction  is  main- 
tained by  the  surgeon,  downward  in  the  direction  of  the  long  axis 
of  the  humerus.     This  method  of  Kocher  mav  be  used  without 


5o6 


NOTES    UPON    A    FliW    DISLOCATIONS 


Fig.  66<).— Second  step  :  Elbow  at  side.     Rotation  of  forearm  outward  to  the  extreme  limit  of 

rotation. 


Fig.  670.— Reduction  of  subcoracoid  dislocation  of  the  humerus.  Third  position  :  Elbow- 
held  at  midpoint  of  thorax,  traction  downward  on  humerus  maintained,  /dotation  of  humerus 
upon  its  long  axis  by  carrying  hand  to  shoulder.  Note  reduction  of  the  dislocation.  The 
head  lies  under  the  acromion  (/)  within  the  capsule  of  the  shoulder-joint  upon  the  glenoid 
cavity  of  the  scapula.     (Lettering  same  as  in  Fig.  666.) 


DISI.OCATION    OK    THE    SHOULDICR 


507 


ether,  or  with  the  aid  of  an  anesthetic.     In  the  great  majority  of 
dislocations  this  method  will  prove  efficient. 

Recurrent  Dislocations  of  the  Shoulder.— These,  if  frequent 
and  troublesome,  may  be  prevented  by  incision  and  by  taking  a 
tuck,  by  means  of  suture,  in  the  capsule.     The  anterior  incision 


Fig.  e-ji.— Third  step  :  While  external  rotation  is  maintained  traction  downward  is  made  and 
at  the  same  lime  the  elbow  is  carried  in  adduction  to  the  mid-line  of  body. 


in  the  sulcus,  between  the  deltoid  and  pectoralis  major  muscles, 
IS  the  better  method  of  approach  to  the  joint  capsule. 

Old  Unreduced  Dislocations.— It  is  not  known  what  the  hmit 
of  time  may  be  within  which  it  is  wise  and  proper  to  undertake 
the  reduction  of  an  old  unreduced  dislocation  uncomplicated  by 
any  fracture.  Each  individual  case  must  be  judged  upon  its 
own  merits.  Suffice  it  to  say  that  several  weeks  may  have  elapsed 
and  yet  a  dislocation  may  be  reduced  by  manipulation.     The 


Fig.  672.— Reduction  of  subcoracoid  dislocation  of  tlie  liumerus  completed.  Note  head  of 
bone  under  the  acromion  (/ )  to  the  outer  side  of  coracoid  process  (w)  and  undisturbed  normal 
anatomical  relations.     (Lettering  same  as  in  Fig.  666.) 


Fig.  673. — Fourth  step :  While  traction  is  being  made,  rotation  inward  is  made  of  the  arm  by 

placing  hand  upon  opposite  shoulder. 

508 


DISLOCATION    OF    THE    HhliOW  509 

dangers  of  attempting  reduction  after  several  weeks  are  injury  to 
important  vessels  and  nerves  and  fracture  of  the  humerus. 

When  moderate  manipulation  has  been  undertaken  and 
failed,  operation  is  indicated.  If  there  is  no  fracture  of  the 
upper  end  of  the  humerus  associated  with  the  dislocation,  it 
may  be  possible,  by  the  assistance  of  the  Porter  and  McBurney 
hook,  to  effect  a  reduction  through  an  open  incision.  Usually, 
when  a  fracture  is  associated  with  a  dislocation,  and  manipula- 
tion and  operation  with  the  aid  of  the  hook  are  not  of  avail,  an 
excision  of  the  head  of  the  bone  becomes  necessarv.  This  opera- 
tion is  attended  with  some  risk  and  yet  useful  arms  are  secured 
by  this  means. 

The  treatment  after  reduction  of  simple  dislocations  of  the 
shoulder  is  important.  After  having  reduced  a  dislocation  it  is 
necessary  to  partially  immobilize  the  shoulder-joint.  This  can 
best  be  accomplished  by  a  swathe  about  the  body,  enclosing  the 
upper  arm,  and  a  cravat  sling  around  the  neck  and  wrist.  The 
body  swathe  may  be  used  only  at  night.  During  the  davtime 
the  arm  may  wear  the  sleeves  of  shirt  and  coat  and  the  wrist  be 
supported  by  a  simple  cravat  sling.  Ordinarily  it  is  customarv 
to  immobilize  the  reduced  shoulder  for  many  weeks  without  giving 
it  any  passive  motion.  It  is  my  experience  that  poor  results 
follow  such  treatment.  It  is  far  wiser  and  safer  to  make  gentle 
passive  motion  upon  the  first  day  after  the  reduction  and  to  con- 
tinue these  gentle  movements  with  increasing  force  and  exertion 
each  succeeding  day,  until  at  the  end  of  a  week  or  a  week  and  a 
half  the  patient  is  no  longer  restrained  in  his  movements,  but  is 
encouraged  to  make  all  movements  that  are  natural. 

DISLOCATION  OF  THE  ELBOW 

The  usual  form  of  displacement  is  of  both  bones  of  the  forearm 
backward.  The  normal  relation  of  the  three  bony  points  of  the 
elbow  is  not  maintained  (see  Elbow  Fractures).  The  olecranon  is 
felt  to  be  posterior  to  the  two  condyles.  There  is  a  shortening  of 
the  forearm.  Lateral  mobility  at  the  elbow  exists.  The  forearm 
is  held  at  an  obtuse  angle.  There  may  be  great  swelling  of  the 
elbow  if  the  injury  is  seen  several  hours  after  the  accident.     This 


NOTES    UPON    A    FlCW    DISLOCATIONS 


Radius. 


Olecranon. 

Fig.  674.— Dislocation  of  both  bones  of  the  forearm  backward  (X-ray,  Massachusetts  C.eneral 

Hospital). 


Fig.  675. — Showing  a  method  of  reduction  of  a  dislocation  of  the  elbow  backward.  Note 
partial  extension  of  forearm  on  arm  ;  position  of  thumbs  of  surgeon  behind  olecranon  making 
pressure  forward  while  fingers  make  pressure  backward. 


DISIvOCATlON    OF    THE)    ril.BOW  51  i 

swelling  will  obscure  the  bony  relations.     Motion  at  the  elbow- 
joint  is  limited  and  painful. 

There  may  be  associated  with  a  simple  dislocation  of  the  elbow 
a  fracture  of  the  olecranon,  of  either  condyle  of  the  humerus  or  a 
fracture  of  the  coronoid  process.     If  there  is  any  doubt  as  to  the 


■ 

|H 

M 

■| 

Head  of 
radius. 

^1 

2 

9 

Fig.  676. — Old  dislocation  of  the  head  of  the  radius  outward  and  backward.  Functional 
usefulness  of  the  elbow  unimpaired.  Pronation  and  supination  normal.  In  such  a  disloca- 
tion were  there  present  any  serious  disability  excision  of  the  head  of  the  radius  would  be 
indicated.     (Codman.) 


Fig.  677.— Same  case  as  figure  676.     Appearance  of  elbows  in  flexion  with  hands  at  side  of 

neck.     (Codman.) 


diagnosis,  ether  should  be  administered  to  facilitate  examination. 
As  Stimson  has  so  well  insisted,  in  the  reduction  of  any  disloca- 
tion the  dislocated  bone  should  be  reduced  by  the  same  path  along 
which  it  came  when  dislocated.  A  haphazard  method  of  reduc- 
tion of  a  dislocation  is  unsurgical. 


512  NOTES    UPON    A    FKW    DISLOCATIONS 

The  best  method  of  reducing  a  dislocation  of  the  forearm  back- 
ward, when  uncomplicated,  is  by  two  steps:  first,  by  completely 
extending  the  forearm,  thus  freeing  the  coronoid  from  the  olec- 
ranon fossa  and  the  posterior  surface  of  the  humerus:  and,  second, 
by  direct  traction  and  then  flexing.  Reduction  is  best  accom- 
plished by  the  aid  of  an  anesthetic. 

Holding  the  arm  extended  and  pressing  with  the  two  thumbs 
upon  the  olecranon  process,  while  the  lower  end  of  the  humerus 
anteriorly  is  grasped  by  the  fingers  of  both  hands  in  counterpres- 
sure,  accomplishes,  of  course,  the  same  end  as  that  accomplished 
by  the  above  procedure,  and  is  in  many  cases  simple  and  efficient 
(see  Fig.  675). 

When  there  is  any  lateral  deformity,  the  bones  should  be  forced 
into  line  before  attempting  to  reduce  the  backward  dislocation. 

The  after-treatment  of  an  uncomplicated  dislocation  of  the 
elbow  is  bv  immobilization  of  the  elbow,  with  the  forearm  at  a 
right  angle  with  the  upper  arm.  A  bandage,  with  equable  pres- 
sure, and  a  sling  to  the  forearm  should  be  applied.  Massage  and 
passive  motion  should  be  used  at  as  early  a  date  as  the  second 
dav.     This  should  be  painless  and  should  be  tentatively  used. 

Good  functional  results  are  to  be  expected  from  uncomplicated 
dislocations  of  the  elbow  occurring  in  young  adults. 

COMPLETE  BACKWARD  DISLOCATION  OF  THE  FIRST  PROXI- 
MAL PHALANX  OF  THE  THUMB 

The  deformity  of  this  dislocation  is  well  shown  in  figure  678. 
The  articular  portion  of  the  base  of  the  phalanx  has  entirely  left 
the  articular  portion  of  the  head  of  the  metacarpal  bone.  The 
two  lateral  ligaments  are  torn.  The  anterior  or  glenoid  ligament 
is  likewise  torn  at  its  attachment  to  the  metacarpal  bone  and  is 
displaced  with  the  phalanx.  Ordinary  traction  only  serves  to 
increase  the  difficult}-  of  reduction,  as  is  illustrated  in  figure  680. 
The  proper  method  of  manipulative  reduction  is  by  completely 
extending  the  thumb  so  as  to  relax  the  tight  adductor  brevis  and 
flexor  longus  pollicis  tendons  and  then  to  push  the  base  of  the 
phalanx  (see  Fig.  682)  forward,  advancing  at  the  same  time  the 
torn   glenoid   ligament   over   the   end    of   the    metacarpal   head; 


DISLOCATION    OF    TllE    TIIUMI'. 


513 


Fig.  67S. — Backward,  dislocalion  of  first  phalanx  of  thumb.     Note  deformily  (  Helferich;. 


Fig.  679. — Same  as  figure  678.     Note  head  of  metacarpal  and  how  it  is  held  by  adductor  brevis 
and  flexor  longus  pollicis  (Helferich). 


--7-n^l     '■ 


.^'^ 


■^^ — 


Fig.  680. — Note  that  traction  alone  accomplishes  no  reduction  but  a  very  tight  grasp  of  the 
metacarpal  head  by  flexor  longus  pollicis  and  the  flexor  brevis  (Helferich). 


33 


514 


NOTES    UPON    A    FEW    DISLOCATIONS 


^^t^tUi>M-'Mli>& 


Fig.  68i.— Proper  method  of  reduction.  Dorsal  flexion  of  thumbs  (true  extension)  ; 
traction  through  dorsal  pressure  by  thumbs  so  that  base  of  phalanx  is  advanced  over  head  of 
metacarpal  (Helferich) 


Fig.  6S2.— Dorsal  dislocation  of  the  terminal  phalanx  of  the  thumb.  Reduced  by  forced 
extension  and  sliding  of  the  extended  phalanx  over  the  end  of  the  first  phalanx.  Note  com- 
plete separation  of  bones.     Glenoid  ligament  is  torn  and  attached  to  the  displaced  phalanx. 


DISLOCATION    OF    THK    HIP 


5 '5 


flexion  will  then  complete  the  reduction.  Immobilization  in  a 
straight  position  for  five  days,  and  after  this  painless  passive  and 
active  movements  together  with  massage  are  indicated.  vShould 
reduction  be  impossible  by  manipulation,  operative  treatment 
will  become  necessary. 


Fig.  6S3.— Dorsal  dislocation  of  the  first  phalanx  of  the  thumb.  X-ray.  Rather  easily  re- 
duced by  slight  extension  and  traction.  Note  that  the  articular  surfaces  touch  each  other  at 
the  margins  of  the  bones 


DISLOCATION  OF  THE  HIP 

A  line  drawn  from  the  anterior  superior  spinous  process  of  the 
ilium  to  the  tuberosity  of  the  ischium  passes  about  midway  across 
the  acetabulum.  The  portion  of  the  bony  pelvis  posterior  to  this 
line  is  called  the  outer  plane  of  the  pelvis.  The  portion  of  the 
pelvis  anterior  to  this  line  is  called  the  inner  plane  of  the  pelvis 
(Allis).  The  hip  is  dislocated  by  a  force  bringing  leverage  to  bear 
upon  the  head  of  the  bone  when  the  thigh  is  flexed  upon  the  ab- 
domen. The  head  of  the  femur  leaves  the  acetabulum  through 
a  rent  in  the  under  portion  of  the  capsule  of  the  joint. 

The  first  movement  of  the  head  in  being  dislocated  is  down- 
ward. According  as  the  head  of  the  bone  slips  to  the  outer  or  the 
inner  plane  of  the  pelvis  will  the  dislocation  be  classified  as  an 


5l6  NOTES    UPO.V    A    FEW    DISI.UCATIOXS 

Diilcr  or  an  iiiiK-r  tlislocalion :  that  is,  a  posU'i'ior  or  an  anlcrior 
dislocation.  ( )!'  conrsf,  in  fillicr  jiiosilion.  wIicIIkt  iIk-  outer  or 
the  inner,  the  head  of  the  bone  may  be  high  up  or  low  down.  The- 
anterior  portion  of  the-  capsule  of  the  hip-joint  is  far  thicker  than 
any  other  ])ortion  of  llie  capsule.  This  thickened  ])ortion  Hige- 
low  called  the  Y-ligament. 

Symptoms. — The  symptoms  of  an  outward  or  dorsal  dislocation 
of  the  hip :  The  limb  is  inverted,  somewhat  shortened,  (lexed 
slighth'  upon  the  abdomen,  the  toes  of  the  dislocated  limb  rest 
upon  the  instep  of  the  other  foot,  the  head  of  the  bcjne  can  be  felt 
above  the  acetabulum.  The  adduction,  flexion,  and  the  rolling 
inward  of  the  limb  are  signs  of  a  dislocation  of  the  hip  outward. 

The  svmptoms  of  an  inward  or  anterior  dislocation:.  The  thigh 
is  flexed  upon  the  abdomen,  abducted,  rotated  outward ;  the  heel 
is  raised,  the  foot  everted. 

Reduction. — The  method  of  reduction  of  an  outward  or  dorsal 
dislocation :  Stimson  advises  very  properly  the  passive  method 
in  uncomplicated  cases.  The  patient  is  placed  prone  on  a  table, 
the  dislocated  leg  is  allowed  to  hang  over  the  end  of  the  table 
while  the  sound  leg  is  held  in  line  with  the  body  by  an  assistant. 
The  surgeon  grasps  the  ankle  of  the  dislocated  leg  and  flexes  the 
knee  to  a  right  angle.  The  weight  of  the  leg  pulling  on  the  mus- 
cles about  the  hip  gently  but  evenly  often,  aided  by  pressure  on 
the  calf  of  the  flexed  leg  on  the  part  of  the  surgeon,  will  reduce 
the  dislocation.  A  slight  rocking  of  the  leg  may  facilitate  reduc- 
tion. 

Allis'  Method. — The  patient  lying  supine,  the  pelvis  being  held 
fixed  by  two  assistants,  the  surgeon  kneels  by  the  patient's  side, 
and  if  the  right  femur  is  dislocated  he  grasps  the  ankle  with  his 
right  hand  and  places  the  bent  elbow  of  his  left  arm  beneath  the 
popliteal  space:  (i)  he  now  turns  the  bent  leg  outward  and  lifts 
upward  (skvward) ;  (2)  then  turns  the  bent  leg  inward  and  brings 
the  femur  down  in  extension. 

The  method  of  reduction  of  an  inward  or  anterior  dislocation  : 

Allis^  Direct  Method. — ( i )  Flex  and  abduct  the  femur.  (2)  Make 
traction  outward.  (3)  Fix  the  head  by  digital  pressure  and 
adduct. 

AUi.';'    Indirect   Method. — Extension,    adduction,    and    outward 


DISLOCATION    OF    THE    HIP  517 

rotation  are  the  movements  made.  The  patient  is  lyinj^  on  tlie 
floor  on  a  blanket  with  Ihc  femur  flexed.  The  surgeon  plaees  his 
bent  elbow  beneath  the  flexed  knee  and  grasps  the  ankle  with  the 
other  hand ;  he  then  extends  with  traction  in  the  line  of  the  long 
axis  of  the  femur,  adducts,  and  rotates  outward. 

Bigelow's  Method  of  Reduction  of  a  Dorsal  or  Posterior  Disloca- 
tion.— The  patient  lies  in  same  position  as  described  above  in 
Allis'  method.  The  thigh  is  flexed,  adducted,  slightly  inverted, 
lifted,  circumducted  outward  and  extended. 

Bigelow's  Method  of  Reduction  of  Thyroid  or  Anterior  Disloca- 
tion.— The  thigh  is  flexed  on  abdomen  to  a  right  angle,  abducted, 
and  rotated  inward  with  adduction  and  is  finally  extended. 


5i8 


NOTES    UPON    A    FEW    DISLOCATIONS 


DISLOCATION  OF  THE  PATELLA 


Fig.  684.— Lateral  dislocation  of  right  patella  (Massachusetts  General  Hospital). 


Fig.  685.— Incomplete  dislocation  of  the  right  patella  outward.  Its  inner  border  rested  in 
the  intercondyloid  notch.  Reduced  by  ether  and  lifting  and  pushing  into  place.  Same  case 
as  that  seen  in  figure  684.     Reduction  is  usually  easy  (Massachusetts  General  Hospital). 


BIBLIOGRAPHY 


The  important  contributions  to  literature  which  have  been  consulted  are  recorded 
below.  Dr.  Stimson's  book  upon  "  Fractures"  will  always  stand  as  a  classical  work 
in  its  especial  field.  Dr.  Poland's  work  upon  "The  Epiphyses"  is  also  a  very 
valuable  contribution  to  fracture  literature.  The  text  has  been  kept  free  of  all 
references  in  order  that  greater  clearness  might  result. 


Hamilton,  Fractures  and  Dislocations. 

Stimson,  A  Practical  Treatise  on  Fractures  and  Dislocations,  Lea  Bros.,  1899. 

Helferich.  Atlas  of  Traumatic  Fractures  and  Luxations,  with  a  Brief  Treatise,  Wm. 

Wood&  Co.,  1896. 
Roberts,  P.  Blakiston,  Son  &  Co.,  Philadelphia,  1897. 
Wharton  and  Curtis,  The  Practice  of  Surgery. 

The  International  Encyclopedia  of  Surgery  ;   supplementary  volume  VII,  1895. 
Dennis,  F.   S.,  System  of  Surgery,  1895. 
Cheever,  Lectures  on  Surgery,  Damrell  and  Upham,  Boston,  1894. 

FRACTURE  OF  THE  SKULL 

Huguenin,  Cyclopaedia  practische  Medicin,  Ziemssen,  Band  xii,  1897. 

Mills,  The  Nervous  System  and  Its  Diseases,  1898. 

Bradford  and  Smith,  Transactions  of  the  American   Surgical  Association,  volume 

LX,  page  433. 
Bullard,  Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  1897. 
Dana,  Text-book  of  Nervous  Diseases. 

Courtney,  Boston  Medical  and  Surgical  Journal,  April  6,  1899,  page  345. 
Hill  and  Bayliss,  Journal  of  Physiology,  London,  1895,  xviil,  page  324. 
Walton,  American  Journal  of  Medical  Sciences,  September,  1898. 
Putnam,  Walton,  Scudder,  Lund,  American  Journal  of  Medical  Sciences,  April, 

1895. 
Phelps,  Traumatic  Injuries  of  the  Brain. 

FRACTURE  OF  THE  NASAL  BONES 

Bosworth,  Diseases  of  Nose  and  Throat,  third  edition,  pages  157-161. 

Zuckerkandl,  Anat.  norm,  et  Patholog.  des  Fosses  Nasales,  volume  I,  page  429. 

Evans,  Deflections  of  the  Nasal  Septum,  Louisville  Journal  of  Surgery  and  Medi- 
cine, volume  V,  June,  1898,  pages  I-4. 

Casselberry,  Deformities  of  the  Septum  Narium,  Transactions  of  the  American 
Medical  Association,  volume  XXII,  No.  9,  pages  469-471 

Cobb,  Fracture  of  the  Nasal  Bones,  Journal  of  the  American  Medical  Association, 
volume  XXX,  1898,  page  588. 

Freytag,  Monatschrift  fiir  Ohrenheilkunde,  1896,  Band  XXX,  Seiten  217-224. 

Zuckerkandl,  Anatomic  der  Nasenhohle,  Band  11. 


520  BIBLIOGRAPHY 

Watsin,  Lancet,  1896,  volume  1.  page  972. 

Roe,  Tlie  American  Medical  (Juailcrly,  June,  1S09. 

FRACTURE  OF  THE  SPINE 

Thorburn,  A  L'onlriljutioii  to  the  Siirj^'ciy  ot'  ilic  Spinal  L'oitl. 

Walton,  Huston  Medical  and  Surgical  Journal,  December  7,  1S93.      The   Journa]  of 

Nervous  and  Mental  Diseases,   January,  1902. 
Thomas,  Boston  Medical  and  Surgical  Journal,  September  7,  1S99,  page  233. 
Dennis,  Annals  of  Surgery,  March,  1IS95. 

Burrell,  Transactions  of  the  Massachusetts  Medical  Society,  1887. 
Taylor,  journal  of  the  Boston  Society  of  the  Medical  Sciences,  December,  1898. 
Wagner  and  Stolper,  Die  Verletzungen  des  NVirbelsaule  und  des  Riickenmarks, 

1S98,  Seile  415. 
Kocher,  Miltheilungen  Grenzgebieten  der  Medicin  untl  Chirurgie,  1896. 
White,  Transactions  American  Surgical  Association,  vol.  ix. 
Cheever,  Boston  Medical  and  Surgical  Journal,  September  28,  1893. 
Pilcher,  Annals  of  Surgery,  volume  xi,  pages  187-200. 
Prewitt,   Transactions  .American  Surgical  .Association,  volume  X\'l,  page  255. 

FRACTURE  OF  THE  SCAPULA 

Blake,  Boston  City  Hospital  Reports,  1899,  page  368. 

FRACTURE  OF  THE  HUMERUS 

Bruns,  Deutsche  Chirurgie,  Theil  28,  2.  Halfte. 
Murray,  New  York  Medical  Journal,  June  25,  1892. 

Monks,  Boston  City  Hospital  Medical  and  Surgical  Reports,  1895  ;  also  Boston 
Medical  and  Surgical  Journal,  March  21,  1895,  January  9,  1896,  and  December 

4,  1895- 

Lund,  Boston  City  Hospital  Reports  for  1897,  page  389. 

Allis,  .Annals  of  the  Anatomical  and  Surgical  Society,  Brooklyn,  1880,  n,  289. 

Smith,  Boston  Medical  and  Surgical  Journal,  July,  1895. 

Stimson,  Roberts,  Allis,  Transactions  of  the  American  Surgical  Association,  1881 
to  1898. 

FRACTURE  OF  THE  FOREARM 

Pilcher,  Paper  read  to  Association  of  Military  Surgeons  of  the  United  States,  Berlin 
Printing  Co.,  Columbus,  Ohio.  Medical  Record,  1878,  11,  74.  Annals  of  An- 
atomical and  Surgical  Association,  Brooklyn,  1887,  in,  page  ^^. 

Moore,  Transactions  of  the  Medical  Society,  State  of  New  York,  1880. 

Bolles,  Boston  City  Hospital  Reports,  third  series,  1882,  page  340. 

Conner,  Journal  of  the  American  Medical  Association,  1894,  page  54. 

Roberts,  Medical  News,  1890,  i.vii,  615.      Annals  of  Surgery,  1892,  xvi. 

Mouchet,  A.,  Revue  de  Chirurgie,  May,  1900. 

FRACTURE  OF  THE  THIGH 
Cabot,  Boston  Medical  and  Surgical  Journal,  January  3,  1884,  page  6. 
Allis,  Transactions  of  the  American   Surgical  A.ssociation,   volume  IX,    1891,   page 

329.      Medical  News,  November  21,  iSgi. 
Hutchinson,  Lancet,  1898,  II,  1630. 
Packard,  International  Encyclopivdia  of  Surgery\ 


BIBLIOGRAPHY  521 

Whitman,  Annals  of  Surgery,  June,  1897,  page  I. 

Senn,  Journal  of  the  American  Medical  Association,  August  3,  1889. 

Ridlon,  Transactions  of  the  American  Orthopedic  Association,  1887,  page  186. 

Lane,  Medicochirurgical  Transactions,  London,  1888. 

Scudder,  Boston  Medical  and  Surgical  Journal,  March  22,  29,  1900. 

SEPARATION  OF  THE  LOWER  EPIPHYSIS  OF  THE  FEMUR 

Annals  of  Surgery,  Philadelphia,  1898,  XXVlii,  664. 

Annals  of  Gynecology,  November,  1890. 

British  Medical  Journal,  December,  1894,  page  671. 

New  York  Medical  Record,  October  5,  1895. 

Annals  of  Surgery,  March,  1896. 

Archives  Generales,  March  and  April,  1884,  volume  XIII,  page  272. 

Transactions  of  the  American  Surgical  Association,  1895. 

Liverpool  Medicochirurgical  Journal,  January,  1885,  page  41. 

Liverpool  Medicochirurgical  Journal,  July,  1883. 

Stimson,  Fractures  and  Dislocations,  1899. 

Hutchinson,  Lancet,  May  13,  1899. 

McBurney,  Annals  of  Surgery,  March,  1896,  XXII,  506. 

Harte,  Transactions  of  the  American  Surgical  Association,  1895. 

Deleus,  Archives  Generale  de  Medicine,  1884,  volume  xiii,  page  272. 

Poland,  Traumatic  Separation  of  the  Epiphyses,  1898. 

Smith,  Transactions  of  the  American  Surgical  Association,  volume  vill. 

FRACTURE  OF  THE  PATELLA 

Powers,  Annals  of  Surgery,  July,  1898. 

Bull,  New  York  Medical  Record,  xxxvii,  1890. 

McBurney,  Annals  of  Surgery,  1895,  ^^'^  3^-- 

Pilcher,  Annals  of  Surgery,  1890,  xii. 

Stimson,  Annals  of  Surgery,  1S95,  XXT,  603  ;    1896,  xxiv,  45. 

Cabot,  Boston  Medical  and  Surgical  Journal,  cxxv. 

Dennis,  System  of  Surgery. 

Lund,  Boston  Medical  and  Surgical  Journal,  1896,  cxxxv,  338. 

Fowler,  Annals  of  Surgery,  January,  1891. 

Macewen,  Annals  of  Surgery,  1887,  volume  v,  page  177. 

Phelps,  New  York  Medical  Journal,  June,  1890. 

White,  New  York  Medical  Record,  October  27,  1888. 

Beach,  New  York  Medical  Record,  March   15,  1890. 

FRACTURE  OF  THE  LEG 
Cabot,  The  Boston  Medical  and  Surgical  Journal,  January  3,  1894,  page  6. 
Lovett,  Boston  City  Hospital  Medical  Reports,  1899,  page  222. 
Allis,  Annals  of  Surgery,  1897. 
Tiffany,  Annals  of  Surgery,  1896,  XXiii,  449. 
Lane,  Transactions  of  the  Clinical  Society,  London,  xxvii,  167. 
Osgood,  Robert,  Transactions  of  the  American  Orthopedic  Association,  1902. 
Stimson,  New  York  Medical  Journal,  June  25,  1892. 

Smith,  N.  R.,  Treatment  of  Fractures  of  the  Lower  Extremity,   Baltimore,  Kelly 
and  Piet,  1867. 


522  BIBLIOGRAPHY 

Osgood,    Robert    B.,    Lesions    of   llie    Tiliial    Tuhercle,    ISoston    Med.    and    Surg. 
luuriKil,    [an.  29,  1903. 

GUNSHOT  WOUNDS  OF  BONE 
Makins,   Geo.   Henry,  Suigical   Experiences  in  .South  iVirica,  1S99-1900  (^voknne 

of  486  jiages,  published  by  Smith,  Elder  &  Co.,  1901). 
Borden,  W.  C,  The  Use  of  the  Rontgen   Ray  by  liie   Medical   Department  of  the 

L'nited  States  Army  in  tiie  NVar  with  Spain,  1898,  Government  Printing  Office, 

1900. 
Kocher,    T.,    Zur    Lehre    von    den    Schusswunden    (lurch    kleinkaliber    Geschosse, 

Cassel,  1895,  Ih-  ^-  Fisher  &  Co. 
La  Garde,  Boston  Medical  and  Surgical  Journal,  January  18,  1900,  p.  57  ;  October 

25,  1900.      Report  of  the  Surgeon-General  of  United  States  Army,  1893. 
Dennis,  System  of  Surgery,  volume  1,  p.  460. 
Treves,  F.,  London  Lancet,  1900,  i,  1359. 
Dent,  C,  British  Medical  Journal,  1900,  11,  632  and  634. 
MacCormac,  Sir  \A^in.,  London  Lancet,  1900,  i,  1485. 
Thomson,  Sir  Wm.,  British  Medical  Journal,  1901,  il,  265.      London  Lancet,  II, 

1901,  264. 
Nancrede,  Transactions  of  the  American  Surgical  Association,  1899,  1900. 
Hall,  Edward  J.,  London  Lancet,  1901,  i,  130,  1755. 

THE  AMBULATORY  TREATMENT  OF  FRACTURES 

Krause,  Deutsche  medicinische  Wochenschrift,  1891,  No.  13. 

Korsch,  Berliner  klinische  Wochenschrift,  No.  2. 

Bruns,  Beitrage  zur  klinische  Chirurgie,  Band  x,  Heft  li,  18. 

Dollinger,  Centralblatt  fiir  Chirurgie,  1893,  No.  46. 

Warbasse,  Transactions  of  the  Brooklyn  Surgical  Society,  October,  1894. 

Bardeleben,  \'erhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIIL  Kon- 

gress,  1894. 
Albers,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIII.  Kongress, 

1894. 
Krause,  Verhandlungen  der  deutsclie  Gesellschaft  fiir  Chirurgie,  XXIIL  Kongress, 

1894. 
Pilcher,  Transactions  of  the  American  Surgical  Association,  volume  xiv,  1896. 
"Woodbury,  New  York  Medical  Record,   1897. 

Roberts,  Transactions  of  the  American  Surgical  Association,  volume  xiv,  1S96. 
"Woolsey,  New  York  Medical  Record,  1897. 
Cabot,  New  York  Medical   Record,  1897. 
Bradford,  New  York  INIedical  Record,  1897. 

THE  EPIPHYSES 
Quain,   Dwight,   Gray,   Morris. 

Poland,  John,  F.R.C.s.,  Traumatic  Separation  of  the  Epiphyses,  1898. 
Briinne,   Das   Verhaltniss  die   Gelenkkapselen  zu   die  Epiphyse  die  Extremitaten- 

Knochen. 
Joiion,  E.,  Revue  D' orthopedic,  Paris,  2e  serie,  3.      1902. 

MASSAGE 

Bennett,  W.   H.,  London  Lancet,  June  2,  1900;   London  Lancet,  Feb.  5,  1898. 


INDEX 


Abscess  of  jaw,  62 

of  nasal  septum,  52 
Acromial  process  of  scapula,  127 

treatment,   129 
Active    motion   after    dislocation    of 
thumb,  515 
after  fracture  of  elbow,  196 
of  leg,  390 
of  patella,   348 
of  shaft  of  femur,   313 
after  separation  of  lower  femoral 

epiphysis,  332 
in  Colles'  fracture,  253 
Adhesive  plaster,   use  of,   in  Colles' 
fracture,  250,  251,  254 
in  fracture  of  clavicle,  119,  123 
of  elbow,   188,   192 
of  hip,  283 
of  humerus,    1 60 
of  metacarpal  bones,  262,  263 
of  nasal  bones,  5 1 
of  olecranon,   228 
of  patella,  344 
of  radius  and  ulna,  215 
of  rib,  98 
of  scapula,    129 
of  shaft  of  femur,  302 
of  sternum,  103 
Pott's  fracture,  404 
Ambulatory  treatment: 

of  fracture  of  clavicle,   119 
of  humerus,    149 
of  thigh,  314 
of  fractures,  48 1 

advantages  claimed,  485 
conclusions,   487 
early  advocates,  481 
materials  for  ordinary  care  of 

closed  fractures,  488 
method  of  application  of  plas- 
ter spUnt  (Bollinger's),  483 
reports  of  cases,  482,  483 
American  Surgical  Association,  con- 
clusions expressing  views  of,  upon 
medicolegal    relations    of    X-rays; 
adopted  m  May,  1900,  457 
Anatomical   neck   of   humerus,    136, 
146,   152 


Anatomical  neck  of  humerus,  after- 
treatment  of  operated  cases, 
152 
fracture,    with    dislocation   of 

upper  fragment,    152 
treatment,  152 
Anesthetics,  use  of,  in  examination: 
of  Colles'  fracture,  234,  239 
of  elbow,   167,  181,  198 

in  dislocation,  5 1 1 
of  femur,  neck  of,  274 

shaft  of,  300 
of  humerus,    anatomical   neck 
of,   136,   146 
surgical  neck  of,  146 
of  leg,  364 

in  open  fracture,  386 
of  maxilla,  superior,  57 
of  nasal  bones,  50 
of  shoulder,   131,  134 
of    separation    of    upper    hu- 
meral epiphysis,  146 
Anesthetics,  use  of,  in  treatment: 
of  Colles'  fracture,  235,  246 
of  dislocation  of  cervical  ver- 
tebrse,  495,  496 
of  elbow,  512 
of  jaw,  497 
of  shoulder,  507 
of  fracture  of  carpus,  257 
of  clavicle,  in  children,  122 
of  femur,  shaft  of,  299 
of  humerus,  146,  160 
of  jaw,  70 
of  malar  bone,  57 
of  radius  and  ulna,  210 
of  vertebrae,  92 
of  greenstick  fracture  of  fore- 
arm, 221 
of  Pott's  fracture,  397,  402 
Ankylosis  of  ankle-joint,   415 
Arthritis,    chronic,    after  fracture   of 

leg,  392 
Asch  tube,  50 

Aspiration  of  knee-joint,  346 
Astragalus,  409 
open  fracture,  415 

operative  treatment,  415 


523 


5-4 


INDEX 


Astragalus,  treatment,  409 
Atrophy,  nniscular,  after  fracture  of 
humerus,   164 


Bandage,  dextrin,  479 
application,   480 
formula,  479 
clastic  rubber,  342 
llannel,  after  Pott's  fracture,  406 
in  fracture  of  humerus,   146,   157 

of  patella,  347 
in  separation    of    lower    foiuoral 

ei^iphysis,  MI 
substituted  for  plaster  si:)hnt,  390 
four-tailed,    in    fracture    of    lower 

jaw,  63 
plaster-of-Paris,  211,  293,  313,  331, 

369,  460 
roller,  in  Colles'  fracture,  2.S1 
in  fracture  of  elbow,   192 
of  femur,  shaft  of,  302 
of  hip,  283 

of  metacarpal  bones,  263 
\'elijeau,    121 
Bardeleben,  quoted:  law  concerning 
ambulatory     treatment     of     frac- 
tures, 483 
Base-ball  finger,  267 
Base  of  skull,  26,  35,  60 
hemorrhage,  27 
nature  of  fractures,  27 
relation     to     fractures     of     the 

vault,  27 
symptoms,  27,  28 
treatment,  39 
Bed-sores,  77,  93,  281 

treatment,  281 
Bennett's  fracture,  259 
Bibliography,  518 
Bladder  (urinary),  rupture  of,  110 
symptoms,   110,   111 
treatment,  oyjerative,  1 1 1 
Blebs,  367,  371 

treatment,  371 
Borden  (\V.  C),  quoted: 

infection  in  gunshot  wounds,  438, 

439 
prognosis  in  gunshot  wounds,  440 
treatment  of  gunshot  wounds,  440 
Bradford  frame,   108,  299,  322 

making  of,  323 
Brain,  abscess  of,  39 
compression  of,  19 
concussion  and  contusion  of,   1 7 
extradural  hemorrhage,   19 
laceration  of,   18 

subarachnoid  serous  exudation,  23 
traumatic  lesions  of,   1  7 
Bryant's    method     of    measurement 
after   fracture   of    neck   of   femur, 
276 


Buck's    extension    ajjparalus    (modi- 
fied), 300 
ai)])lication,   303 
in  childhood,  320 
materials  reciuired,  300 
BuUard,  Dr.  (Boston  City  Hospital) 
(juoted : 
results  of  fracture  of  skull,  39 


Cabot  ]josterior  wire  splint,  320,  344, 
376 
application,   322 
co\ering,  376 
making,  376 

padding  of,  for  reception  of 
lower  extremity,  378 
Carpus,  256 
symptoms,  257 
treatment,  257 
Clavicle,   112 
anatomy,   112 
operative  treatment,   123 

in  ununited  fractures,  123 
prognosis,    123 
symptoms,    1 13 

in  childhood,    1 14 
treatment  in  adults,   115 

modified  vSayre  dressing,   119 
recumbent,    115 
treatment  in  children,   121 
Codman    (Ernest   Amory) :   Rontgen 
ray  and  its  relation   to  fractures, 
444 
Colles'  fracture,  232 
anatomy,  232 
difTerential  diagnosis,  240 

contusion     of     bones     near 

wrist-joint,  241 
dislocation    of    wrist    back- 
ward, 242 
fracture  of  shaft  of  one  or 
both  bones  low  down,  242 
separation    of   lower  epiph- 
ysis of  radius,  244 
sprain  of  the  wrist,  240 
lesions  associated  with,  246 
operative   treatment   for   result- 
ing deformity,   255 
prognosis  and  result,  254 
"reversed  Colles'"  fracture,  254 
symptoms,  235 
treatment,  246 

a  method  of  reduction,  247 
retentive  apparatus,  250 
application  of,  250 
Coma,  31.  34 
alcoholic,  31 

from  hemorrhagic  internal  pachy- 
meningitis, 32 
from  opium-poisoning,  31 
Compression  of  brain,  19 


INDEX 


52.5 


Compression  of  brain,  symplonis,  1 9 

Concussion    and    contusion    of    the 

brain,   1 7 

symptoms,   17,  34,  35 

temperature,   18,  35 

Consciousness    and    unconscicjusness 

in  extradural  hemorrhage,  20,  35 
Contusion  of  bones  near  wrist-joint, 

241 
Coracoid  process  of  scapula,  134 
Coxa  vara,  291 

Cystitis  after  fractures  of  the  verte- 
brae, 77,  81,  92 


Deformity,  after  fracture  of  clavicle, 
123 
of  femur,  shaft  of,  307 

backward  sagging,  308 
eversiOn  of  foot,  308 
outward  bowing,  308 
of  leg,  366,  376 
of  malar  bone,  54 
of  nasal  bones,  45,  47 
in  Colles'  fracture,  235,  255 
anteroposterior,  235 

silver-fork   deformity,    236 
lateral,  236 

slight  deformity  only,.  239,  241 
in  fracture  of  elbow,  193 

of  metacarpal  bones,  265 
of  radius,  shaft  of,  205 
of  radius  and  ulna,   199 
of  vertebrae,  76,  91 
in  greenstick  fracture  of  bones  of 

forearm,  199 
in  Pott's  fracture,  396,  407 

reversed  Pott's  deformity,  397 
in  separation  of  lower  radial  epiph- 
ysis, 245 
Dislocation  of  hip,  273,  277 
of  humeral  head,    135,    152 
reduction,   152 
results,  153 
treatment,  152 
operative,   152 
of  knee,  327 

of  radius  and  ulna  backward,  with 
or  without  fracture  of  coronoid 

process  of  ulna,  174 
treatment,  193 
of  vertebrae,   73 
of  wrist,  backward,  242 
Dislocations,  notes  upon,  489 
of  cervical  vertebrae,  489 
bilateral,  489 
combined  with  fracture  of  an 

articular  process,  494 
precautions,  496 
spontaneous  reduction,  495 
treatment,   495 

of  bilateral  dislocation,  496 


Dislocations     of    cer\'ical    vertebra;, 
unilateral,  489 
signs,  490 
untreated  cases,  495 
of  clavicle,  500 
of  elbow,  509 

after-treatment,  512 
associated  with  fracture,  511 
signs,  509 
treatment,  512 
of  hip,  515 

reduction,  516 

Allis'  method,  516 
of  a   dorsal   or   posterior  dis- 
location: Bigelow's  method, 
517 
I        of     an     inward     or     anterior 
dislocation:    Allis'    direct 
method,  516 
Allis'  indirect  method,  516 
Bigelow's  method,  517 
symptoms,  516 
of  jaw,  496 
signs,  496 

spontaneous  reduction,  496 
treatment,  497 

of  irreducible  dislocations,  499 
of  recurring  dislocations,  499 
of  patella,  518 
of  shoulder,  501 

associated    with    fracture,     503, 

509 
old  unreduced  dislocations,  507 

treatment,  509 
recurrent  dislocations,  507 
signs,  501 
treatment,  503 

after  reduction,  509 
Kocher's  method,  504 
of  thumb,  complete  backward  dis- 
location     of     first      proximal 
phalanx,  512 
signs,  512 
treatment,  512 
operative,  515 
Dollinger's  method  of  application  of 
plaster  splint  in  ambulatorv  treat- 
ment of  fractures,  482,  483 
Drainage  in  open  fracture  of  leg,  389 
in  open  Pott's  fracture,  408 
of  mouth  after  fracture  of  jaw,  60 
Dupuytren  splint,  400 
application,  401 
defect,  402 


EccHYMOSis  in  fracture  of  leg,  367 
in  fracture  of  skull,  30,  31 

Edema,   causes  of,   after  fracture  of 
leg  or  thigh,  394 
cerebral,  23 
malignant,  332 


,26 


INDEX 


Elbow,  167 

after-care,   194 
method  of  examination,   167 
carrying  angle,  169 
head  of  radius,  168 
measurements,   169 
movements  at  elbow-joint,  169 
palpation   of   the   three   bony 

points,   168 
summary   of   order   of   exam- 
ination,  171 
the  three  Ijony  points,   168 
omission  of  spUnt  or  retentive  ap- 
paratus,  196 
prognosis,   197 
traumatic  lesicms  of,    172 

of  lower  end  of  humerus,    1 74 
of  radius  and  ulna,  172 
symptoms,  174 
treatment,   182 

acutely  flexed  position,  182 
method  of  using,  186 
precautions  in  using,   189 
Elbow-joint,    treatment   of,    in   frac- 
ture of  shaft  of  humerus,  161 
EmboHsm,  394,  487 
fat,  333 

prognosis,  334 
symptoms,  334 
treatment,  334 
Emergency  method  of  putting  up  a 

fracture  of  thigh  or  hip,  296 
Emphysema    in    fracture    of    nasal 
bones,  48 
of  ribs,  96,   100 
of  superior  maxilla,  57 
Epiphyses,  anatomical  facts  regard- 
ing the,  418 
acromion  process  of  scapula,  430 
date  of  appearance  of  ossification 
in  chief  epiphyses  of  long  bones, 
(after  Poland),  418 
femur,  lower  epiphysis,  429 
humerus,  upper  epiphysis,  419 

activity    of,    in    growth    of 
shaft,  429 
lower  epiphysis,  430 
importance    of    exact    knowledge, 

418 
order   of   frequency   of   separation 

(after  Poland),  4l9 
pain    in    separation    of    epiphyses 
compared  with  pain  from  frac- 
tures, 419 
radius,  lower  epiphysis,  429 
tibia,  lower  epiphysis,  430 
upper  epiphysis,  430 
Epiphysis,   fracture  of  lower  radial, 

246' 
Epiphysis,  injury  to  lower  humeral, 
179 
diagnosis,  180 


Epiphysis,  separation  of: 
femoral,  lower,  324 
anatomy,  324 
com])lications,  326 
diagnosis,  326 
prognosis,  327 
treatment,  329 

of     traumatic     gangrene, 
septicemia,     malignant 
edema,  33>3 
ojjerative   method   of   re- 
duction, 330 
reduction    by    manipula- 
tion when  fragment  is 
disjjlaced  forward,   330 
humeral,  lower,  178,  179 

treatment,  193 
humeral,  upper,   137,   146 

after-treatment  of  operated 

cases,   152 
prognosis,   145,   151 
treatment.  144 

operative,   145 
with    dislocation    of    upper 
fragment,    152 
radial,  lower,  206,  244 

treatment,  206,  217,  245 
tibial,  lower,  368 
tibial,  upper,  361 
treatment,  363 
Epiphysis    of    acromion    process    of 

scapula,  127,  430 
Ethmoid,  cribriform  plate  of,  28 
Excision  of  head  of  humerus,   152 

results,   153 
Extension  weights  after  fracture  of 
hip,   283 
of  shaft  of  femur,  306,  307, 
314 
Extravasation  of  urine,   110,   111 


Face,  bones  of,  45 
malar  bone,  53 
maxilla,  inferior,  60 

superior,  57 
nasal  bones,  45 
Feeding,    after   fracture   of   jaw,    by- 
mouth,  59,  72 
nasal,  59 
Femur,  270 

after-treatment  and  prognosis,  312 
anatomy,  270 

examination,   method  of,   300 
gunshot  fracture,  441 
mortality,  442 

comparative,     in     different 
wars,  442 
prcjgnosis,  443 
symptoms,  441 
treatment,  442 
in  childhood,  319 


INDEX 


527 


Femur  in  childhood,  symptoms,  320 
treatment,  320 

Buck's  extension,  320 
Cabot    posterior    wire    spHnt, 

320 
plaster-of-Paris    spica    sphnt, 
320 
neck  of.     See  Hip. 
prognosis,  315 
results,  316 

in  adult  life,  317 
in  childhood,  317 
in  old  age,  318 
shaft  of,  293 

measurement,  294 

Dr.  Keen's  method,  296 
symptoms,  294 
subtrochanteric  fracture,  309 
symptoms,  309 
treatment,  309 
operative,  310 
supracondjdoid  fracture,   311,   327 
symptoms,  311 
treatment,   311 
treatment,  296 

Buck's       extension       apparatus 

(modified),  300 
emergency  treatment,  296 
transportation     of     a      patient, 
296 
Fissure    of    Rolando,    indications    of 

lesion  about,  19 
Flat-foot,  traumatic,  415 

treatment,  415 
Foot,  bones  of,  409 
astragalus,  409 
metatarsal  bones,  415 
open  fracture  of  astragalus  and 
OS  calcis,  415 
operative  treatment,  415 
OS  calcis,  411 
phalanges,  417 
Forearm,  bones  of,   199 
Colles'  fracture,  232 
olecranon,  222 
radius  and  ulna,   199 


Gangrene  of   leg,   after  fracture  of 
femur,  319 
of  lower  leg,  369 

treatment,  372,  373 
in  separation  of  lower  femoral  epi- 
physis, 326 
traumatic,  332,  373 
Greenstick  fracture  of  bones  of  fore- 
arm, 199 
treatment,  221 
of  clavicle,  114,  122,  123 
of  hip,  291 

treatment,  293 
Gunshot  fractures  of  bone,  431 


Gunsh<jt   fractures  of  bone,  changes 
in    construction  of    modern 
mihtary  rifle,  431 
classification  of  parts  of  long 

bones  injured,  433 
comparison  of  old  and  modern 

bullets,  437 
disinfection  of  limb,  440 
explosive  effect  of  bullet,  433 
factors  upon  which  amount  of 
damage    to    bone    is 
dependent,  431 
resistance,  433 
revolution  of  bullet,  432 
shape  of  bullet,  431 
velocity  of  bullet,  431 
prognosis  in  fractures  of  femur, 

443 
ricochet  bullet,  436 
treatment,  438 

first  field  dressing,  439 
fracture  of  femur,  442 
infected  wounds,  440 
noninfected  wounds,  439 
operative,  440,  441 
uncomplicated  injuries,  433 
wounds  of  entrance  and  exit, 

436 
wounds  of  modern  projectiles 
less  grave,  438 


Head  injury,  cases  of,  40 

I.  Middle  meningeal  hemor- 
rhage with  fracture  of 
skull,  40 

II.  Open  depressed  fracture 
of  skull;  paralysis  of  one- 
half  of  body,  42 

III.  Middle  meningeal  hemor- 
rhage ;  fracture  of  skull,  44 

Heel,  care  of,  in  treatment  of  frac- 
ture of  hip,  281,  283 
of  leg,   377 

of  Pott's  fracture,  404 
of  shaft  of  femur,   306,  312 
Hematoma   of  cartilaginous   septum 
of  nose,  52 
of  scalp,  26 
Hematomyeha,  86,  87,  88,  89,  90 
Hemoptysis  in  fat  embolism,  334 
Hemorrhage,  extradural,   19,  86,  88 
consciousness   and   unconscious- 
ness, 20,  35 
semiconsciousness,  period  of,  23 
sources,  20 
symptoms,  19 
in  fracture  of  base  of  skull,  27,  28, 
30 
of  humerus,  153 
of  leg,   372 
of  superior  maxilla,  58 


528 


IXDHX 


Hemorrhage  into  pliarynx,  30 

into   spinal   cord,    86,.  87,    88,    89, 

90 
meningeal,  39 
middle   meningeal,    cases   (;l",    with 

fracture  of  skull,  40,  44 
middle  meningeal  vs.  hemorrliagic 

pachymeningitis,  32 
sul)Conjuncli\'al,   28,   30,    56 
temperature  in  intracranial  lesions, 
35 
Hip,   or  neck  of  femur,    271 
anatomy,  270 
fracture  in  adults,   271 
examination,  273 
impacted       and        unim- 

pacted,  272,  273 
measurement,  275 

Bryant's  method,  276 
prognosis  and  result,  278 
results  after,  279 
symptoms,  272 
treatment,  280 

after-care   of   simple 

traction  method,  283 
fixation  method,  284 
Thoinas      hip-splint, 
285 
general   considerations, 

280 
operative,  291 
treatment   of  the   frac- 
tured hip,  282 
fracture  in  childhood,  291 
immediate  result,  291 
late  result,  291 
symptoms,  291 
treatment,  293 

of   greenstick   fracture, 
293 
Hot-air  treatment,  255,  415 
Humerus,  130 

lower  end,  lesions  of,   174 

fracture   of  external   condyle, 
178,  201 
of  internal  condyle,   1 78 
of  internal  epicondyle,   178 
injury  to  lower  humeral  epiph- 
ysis,  179 
separation   of   lower   humeral 

epiphysis,  179 
T-fracture     into    elbow-joint, 

180 
transverse  fracture  above  the 
condyles,  178,  191 
treatment,  191 
shaft  of,  153 

after-treatment,   161 
fractures  in  the  newborn,  164 

treatment,  164 
musculospiral  nerve  in  fracture 
of  humerus,  164 


Humerus,   shaft  of,   oi)erative  treat- 
ment,  162 
])rognosis,  163 
symjjloms,    153 
treatment,  156 

of  fractures  with  considerable 

displacement,   162 
of  fractures   with   little   or   no 
dis])lacement,   157 
ui)per  end,  130 

after-care,   149 

anatomy,   130 

diagnosis,  134 

dislocation   of   humeral  head, 

simple  coracoid,  135 
examination  t)f  shoulder,  131 
fracture   of    anatomical  neck, 
136 
of  surgical  neck,   145 
prognosis  and  result,   151 
separation  of  ujjpcr  e])ip]i\'sis, 
137 
prognosis,   145,   151 
treatment,  144 
Hysteroid  semiconsciousness,  23 


Ice  bag,  374 
lUum,  106 

Infection,    in   compound   fracture   of 
skull,  34 
in  fracture  of  base  of  skull,  27,  36 
of  maxilla,  inferior,  62,  72 

superior,  58 
of  metatarsal  bones,  417 
of  nasal  bones,  47 
treatment,  52 
in  gunshot  wounds,  439,  440 
in  open  fracture  of  leg,  386 
of  phalanges  of  hand,  268 


Keen's    method    of    measuring    in 

fracture  of  shaft  of  femur,  294 
Kocher's    classification    of    parts    of 
long     bones    injured     in     gunshot 
wounds,  433 
Kocher's   method   of  reducing  dislo- 
cation of  the  shoulder,  504 
Krause,      quoted :     on     ambulatory 
treatment  of  fractures,  481 
advantages,  487 
Hmits  of  its  use,  482 
table,  from  Paul  Bruns,  contain- 
ing  average   periods   of  heal- 
ins:,  486 


Laceration  of  the  brain,  IS 
symptoms,   18,  28 
temperature,   18,  35 


INDEX 


529 


La  Garde,  quoted :  wounds  of  modern 

projectiles,  438 
Lee-Metford    (English)    bullet:    size, 

weight,  and  velocity,  438 
Leg,  357 

after-care,  391 
anatomy,  357 
examination,  363 
general  observations,  360 
Pott's  fracture,  394 
prognosis,  392 
results,  393 
refracture,  394 

thrombosis  and  embolism,  394 
symptoms,  365 
treatment,  368 

care  of  fracture  after  permanent 
dressing     has     been    applied, 
389 
fractures    difficult    to    hold    re- 
duced, 383 
operative  treatment,  385 
fractures  with  considerable  im- 
mediate swelling,  370 
care  of  heel,  377 
operative       treatment,      372, 

373 
permanent  dressing,  375 
temporary  dressing,  374 
in    fractures    with    little    or    no 
displacement  or  swelling,  368 
open  fractures,  386 

permanent  dressing,  386 
temporary  dressing,  386 
wound  of  soft  parts,  387 
Lesions  following  injury  to  definite 

vertebrae,  table  of,  75 
Limitation    of   motion    after   Colles' 
fracture,  254,  255 
after  fracture  of  bones  of  fore- 
arm, 220 
of  elbow,  198 
of  humerus,  151 
of  olecranon,  230 
of  patella,  351 

of  scaphoid  bone  of  wrist,  257, 
259 
after  open  fracture  of  astragalus 

and  OS  calcis,  415 
after  separation  of  lower  femoral 
epiphysis,  332 


MacCormac    (Sir  William),   quoted: 
treatment   of  gunshot  fracture   of 
femur,  442 
Makins     (George     Henry),     quoted: 
difficulties   of  frequent   dressing 
of  gunshot  fractures,  440 
gunshot  fracture  of  femur,  441 
gunshot  wounds  in  South  African 
war,  433 
34 


Makins,  prognosis  in  fractures  of  the 
femur    ((juoted    from    "Surgical 
Kxperiences"),  443 
treatment  by  amputation,  441 
Malar  Ijone,  53 

complications,  56 
examination,  53 
symptoms,  54 
treatment,  56 
treatment,  operative,  57 
Malignant  disease,  167 
Massachusetts  General  Hospital,  cases 
treated  at: 
results  after  fracture  of  femur, 
317 
of  hip,  280 
of  leg,  393 
of  patella,  352 
statistics   concerning  ambula- 
tory treatment,  486 
Massage,  after  dislocation  of  elbow, 
512 
of  thumb,  515 
after  fracture  of  bones  of  forearm, 
219 
of  carpus,  258 
of  clavicle,  123 
of  elbow,  195,  196 
of  femur,  shaft  of,  313,  314 
of  humerus,  150,  153,  162 
of  leg,  390,  392 
of  metacarpal  bones,  265 
of  patella,  343,  348 

with  operative  treatment,  356 
of  ribs,   100 
of  scapula,  129 
after  Pott's  fracture,  406,  407 
after  separation   of  lower   femoral 

epiphysis,  332 
for  traumatic  flat-foot,  415 
in  Colles'  fracture,  253,  255 
in  fracture  of  astragalus,  409 
of  olecranon,  229 
of  OS  calcis,  412 
Materials  for  ordinary  care  of  closed 

fractures,  488 
Mauser  bullet: 

revolution  of,  432 
size,  weight,  and  velocity,  438 
Maxilla,  inferior,  60 
examination,  61 
fracture  of  body  of  jaw,  63 
fracture  of  coronoid  and  articu- 
lar processes,  72 
fracture   of  ramus,   just   behind 

molar  teeth,  70 
fracture    of    ramus    upon    same 
or   opposite    sides  of   inferior 
maxilla,  71 
symptoms,  61 
treatment,  63 
superior,  57 


530 


INDEX 


Maxilla,  superior,  afler-care,  59 
diagnosis,  57 
trealmenl,  58 
McBurney-Porter     hook     iiuiiKfuvcr 
in  reducing  a  dislocated  shuuUkT, 
152 
McGraw's  method  of  reducing  old  ir- 
reducible dislocations  of  the  jaw, 
499 
Measurement  in  Colk-s'  fraclurt',  2.U 
in  dislocation  of  humeral  head,  136 
in  fracture  of  elbow,  169 
of  external  condyle,  178 
of  femur,  neck  of,  274,  275 

shaft  of,  294,  308,  312 
of  humerus,   133,   156 
of  leg,  365,  376 
in  Pott's  fracture,  396 
in  T-fracture  into  elbow-joint,   180 
Metacarjxil  bones,  259 
svmjjtoms,  259 
treatment,  260 
Metatarsal  bones,  415 
complications,  417 
symptoms,  416 
treatment,  417 
Morphin,  use  of,  382 
Musculospiral    nerve    in   fracture    of 
humerus,   153,   164 
prognosis,   167 
symptoms    of    compression, 
165 
of  contusion,  165 
of  injury,   165 
treatment,  167 
operative,  167 

NancrEde,    quoted:   amputation    of 

long  bones,  440 
deflection     of    luiUet     in    gunshot 

wounds,  436 
Nasal  bones,  45 

anatomy,  45 

complications,  47 

in  combination  with  fracture  of 
the  septum,  49 

prognosis,  52 

symptoms,  47 

treatment,  50 
septum,  abscess  of.  52 

dislocation,  48,  49 

hematoma,  52 

horizontal  fracture,  49 

in  fracture  of  nose,  48 

lesions,  49 

sigmoid  deviation,  49 

treatment,  50 

vertical  fracture,  49 
Necrosis,   after  fracture  of  humerus 

with   dislocation  of  upper  frag- 
ment, 152 


Necrosis  after  fracture  of  jaw,  lower, 
62,  72 
u])|)er,  58 
of  metatarsal  bones,  417 
after  ojjen  fracture  of  leg,  392 
after  separation  of  lower  femoral 

epijjhysis,  326,  329 
in  ojjcn  fractures  of  phalanges,  268 
Nerves,  lesions  of,  in  fracture  of  base 
of  skull,  28,  29,  30 
of  floor  of  orbit,  56 
of  humerus,   153 
of  superior  maxilla,  58 
in   separation   of   lower   femoral 
epiphysis,  326 
of  the  spinal  cord,  anatomy  of,  74 
Neuritis,  fc^Uowing  injury  to  muscu- 
lospiral nerve,  165 
Nonunion  of  fracture  of  clavicle,  123 
operative  treatment,  123 
of  femur,  neck  of,  278 
of  humerus,   163 
of  leg,  392 

of  phalanges  of  hand,  269 
of  fractures,  220 
causes,  221 
treatment,  221 
operative,  22 1 
Nose,  dangers  of  blow  upon,  52 
deformity  of,  from  fracture,  45,  47 
from  syphilis,  47 
Notes  upon  a  few  dislocations,  489 
Nussbaum,  von,  quoted:  first  dress- 
ing of  gunshot  wounds,  439 


Olecranon,  222 
after-care,  229 
anatomy,  222 
process,   176 

summary  of  treatment,  231 
symptoms,  225 
treatment,  226 

in  open  fracture,  228 
operative,  228,  231 
Orbital  plate  of  frontal  bone,  28 
Os  calcis,  411 

open  fracture,  415 

operative  treatment,  415 
results,  415 

flat-foot,  415 
symptoms,  41 1 
treatment,  412 
Osgood,  Dr.  Robert,  quoted:  partial 
separation  of  upper  tibial  epiphy- 
sis, 361 


Paralysis  in  fracture  of  humerus,  1 33 
of  skull,  19,  35 

of  vertebra;,   76,   77,   79,   80,   81, 
82,  89 


INDEX 


531 


Paralysis,  obstetrical,   164 

of  musculospiral  nerve,   153,   165 
Passive   motion  after  dislocation   of 
elbow,  512 
of  shoulder,  509 
of  thumb,  515 
after  fracture  of  bones  of  fore- 
arm, 219 
of  carpus,  258 
of  clavicle,  123 
of  elbow,  194,  196 
of  femur,  shaft  of,  313,  314 
of  humerus,  149,  152,  153,  162 
of  leg,  390 
of  patella,  348 

with    operative    treatment, 
356 
after  Pott's  fracture,  406 
after  separation  of  lower  femoral 

epiphysis,  332 
in  Colles'  fracture,  253,  255 
in  fracture  of  astragalus,  409 
of  olecranon,  230 
Patella,  335 
anatomy,  335 
open  fracture,  349 

treatment,  349 
operative    interference    in    recent 
closed  fractures,  354 
conditions  suitable,  355 
danger  of  sepsis,  354 
fractures,  354 
indications,  356 
method    of    operation, 

356 
restoration  of  function 
of  joint  following  op- 
erative      treatment, 
356 
prognosis,  350 
results,  352 
symptoms,  337 
treatment,  340 

limitation  and  removal  of  effu- 
sion, 342 
maintenance  of  reduction  until 

union  is  satisfactory,  346 
reduction  of  fragments,  344 
restoration  of  function  of  joint, 

348 
summary   of   treatment   by   ex- 
pectant       or        nonoperative 
method,  348 
Pelvis,  104 

complications,  108 

rupture  of  urethra,  109 

of  urinary  bladder,  1 10 
visceral  lesions,   108 
examination,  105 
prognosis,  1 1 1 
treatment,  106 
Phalanges,  265,  417 


Phalanges  of  the  foot,  417 
treatment,  417 
of  the  hand,  265 
ojjen  fractures,  268 

operative  treatment,  269 
symptoms,  267 
treatment,  267 
Plaster-of-Paris,  employment  of,  460 
application  tc;  patient,  476 
dextrin  bandage,  479 
making  of  Ijandages,  460 
removal  of  the  plaster  splint,  479 
rolling  the  ]jlaster,  460 
Plaster-of-Paris  jacket,  90 

method  of  applying,  9 1 
Plaster-of-Paris  roller  Ijandage,  346 
method  of  making,  346 
sphnt,  346 

spica,  320,  442 
traction,  384 

method  of  application,  384 
Plaster-of-Paris     shoulder-cap,      146, 

149 
Pleurisy  in  fracture  of  ribs,  96 
Pneumonia,  hypostatic,  81,  278,  281 
Poland,  John  (his  "Traumatic  Sepa- 
ration of  Epiphyses"  quoted),  418 
Porter  and  McBurney  hook,  152,  509 
Pott's  fracture,  394 
anatomy,  394 

lesions  which  may  be  present,  395 
open  fracture,  408 

indications  for  amputation, 
408 
operative  treatment  of  old  frac- 
tures, 408 
symptoms,  396 
treatment,  397 

care  after  permanent  dressing 

is  applied,  405 
Dupuytren  sphnt,  399,  400 
lateral  and  posterior  plaster- 
of-Paris    splints    (Stimson's 
sphnt),  404,  406,  407 
posterior     wire     splint     with 
curved  foot-piece,  402,  407 
prognosis  and  results,  407 
support  of  arch  of  the  foot,  407 
Pressure  sores,  288,  369,  377,  391,  487 
treatment,  288 
lateral,  in  fracture  of  hip,  291 
Pubic  portion  of  ring  of  pelvis,  106 
Pulse  in  fracture  of  hip,  281 
of  leg,  365 
of  skull,  18,  19,  36 


Radio-ulnar  joint,  inferior,  involve- 
ment of,  in  Colles'  fracture,  255 
Radius  and  ulna,  199 

incomplete    or    greenstick    frac- 
ture, 199 


J.S-' 


INDI-:X 


Radius  and  ulna,  prognosis  and  re- 
sult, 220 
symptoms,  199 
treatment,  210 

of  open  fraelures,  21'' 
Radius,  Iraeture  of  neck  or  head,  1  78, 
201 
symptoms,  201 
treatment,  194 
fracture  of  shaft,  202 
symptoms,  204 
treatment,  21  7 
operatixe,  217 
Reflexes  in  fractures  of  the  vertebra;, 

76,  80,  82 
Refracture    of    bones    of    the    lower 

extremity,  394 
Respiration  in  fat  embolism,  334 
in  fracture  of  hip,  281 
in  fracture  of  skull,  19,  36 
in  fractures  of  the  vertebrae,  80 
Retention  and  inct)ntinence,  in  con- 
cussion of  brain,   18 
in  fracture  of  vertebrae,  77 
Rheumatism,  chronic,  278 
Ribs,  95 

after-treatment,   100 
anatomy,  95 
complications,  96 
symptoms,  95 
treatment,  96 
operative,  100 
Roe's  elevator,  50 

Rontgen  ray  and  its  relation  to  frac- 
tures, 444 
assistance  in  diagnosis,  451 

in  examination,  451 
Crookes  tube,  445 
effects  of  X-rays,  extent  of,  446 
accuracy  and   inaccuracy  of 

pictures,  450 
distortion  of  shadows,  446, 
453 
fluoroscope,  445,  45'3 
forms  of  fracture  in  which  X-ray 
gives   great   assistance: 
elbow-joint,  453 
femur,  454 
foot,  bones  of,  455 
leg,  lower,  455 
patella,  449,  455 
shoulder-joint,  453 
wrist,  454 
in  knowledge  of  pathology  and 

treatment  of  fractures,  451 
medicolegal  relations  of  X-rays ; 
conclusions  expressing  views 
of  American  Surgical  Associa- 
tion, adopted  in  May,  1900, 
457 
use  in  demonstrating  to  students, 
452 


Riintgen  ray,  use  of,  as  a  method  of 
record  in  rare  fractures,  452 
X-ray  burns  and  dermatitis,  455 
X-ray   i)iclure  and   ])hotograpli, 
comparison  of,  445 
Rontgen  ray  in  diagnosis  of  Colles' 
fracture,  239,  241,  242,  244, 
248 
of  fracture  of  astragalus,  409 
of  carpus,  256 
of  coronoid  j^rocess  of  ulna, 

210 
of  elbow,   182 
of  femur,  neck  of,  278 
of  humerus,  134 
of  radius,  neck  and  head  of, 
201 
in  dislocation  of  shoulder,  503 
in  gunshot  fractures,  439 
in  knowledge  of  epiphyses,  418 


Sand-bags,  283,  303,  307 

Sayre  dressing  (modified)  in  fracture 

of  clavicle,   119,  122 
Scaphoid  bone  of  wrist,  256 

anomaly     of,      mistaken     for 
fracture,  257 
Scapula,   125 

acromial  process,   127,   129 
body  of,  125,  129 
neck  of,  127 

treatment  in  general,  128 
Sepsis.     See  Injcctioji. 
Septicaemia,  332 

Shock,  after  fracture  of  femur,  neck 
of,  278 
shaft  of,  319 
of  jaw,  59 
of  pelvis,  109 
of  vertebrae,  93 
after  gunshot  fracture  of  vertebrae, 

93 
after  rupture   of  urinary   bladder, 

111 
after  separation  of  lower  femoral 

epiphysis,  326 
in  gunshot  fracture  of  femur,  441 
Short-Desault  apparatus,  384 
Lovett's  adaptation,  384 
Shortening  of  bone,  after  separation 
of    lower    femoral    epiphysis, 
328 
in  fracture  of  femur,  neck  of,  273, 
278 
shaft  of,  307 
of  leg,  365,  392 
vSilver-fork  deformity,  236 
Skull,  17.  23 
after-care,  39 
cases  of  head  injury,  40 
compression  of  brain,  19 


INDEX 


533 


Skull,    concussion   and  contusion    of 
brain,  17 
diagnosis,  34 

examination  of  patient,  .^2 
general  condition,  33 
local  condition,  33 
extradural  hemorrhage,  19 
fracture  of  base,  26 

of  vault,  26 
general  observations,  34 
laceration  of  brain,  18 
later  results  of  fracture,  39 
nature  of  fracture,  23 
operative  interference,  37,  40 
prognosis,  39 

subarachnoid  serous  exudation,  23 
treatment,  35 
ear,  36 
mouth,  37 
nose,  36 
scalp,  36 
unconsciousness   resulting  from 
other  than  surgical  causes,  31 
Sling  for  CoUes'  fracture,  251,  254 
for  fractured  clavicle,  123 
elbow,   189 

humerus,   149,  160,  161,  162 
radius  and  ulna,  218 
Smith  anterior  wire  splint,  383 
Spinal  cord,  anatomy,  73 

lesions  of,  73,  82,  86,  93 
how  to  localize,  74 
operative   treatment,    85,    86, 

87,  90 
prognosis,  86 
transverse  and  partial,  82 
how  to  distinguish,  82 
Spine,  injury  to,  examination,  76 
•Splints  for  Colles'  fracture,  250 
for  fracture  of  astragalus,  409 
of  carpus,  258 
of  elbow,  182 

internal  right-angle,   191 
right-angle    internal    angular, 
182 
of  femur,    shaft    of,    emergency, 

297 
of  humerus,  coaptation,  146,  159, 
162 
internal  angular,  161 
plaster-of-Paris,  162 
of  jaw,  buckle  and  strap,  71 
chin-piece,  68,  71 
dental,  58,  59,  63,  65,  68,  71 

making  of,  68 
silver  wire,  64 
of  leg,  light  plaster,  390 
pillow  and  side,  374 
plaster-of-Paris,  369,  374,  380, 

383,  389 
posterior  wire  and  side,   375, 
376,  383,  389 


vSplints  for  fracture  of  leg,  .Smitli  an- 
terior wire,  3X3 
of  nietacar])al  Ijoncs,  263 
(jf  metatarsal  bones,  417 
of  nasal  bones,  5 1 
Cobb's,  51 
Coolidgc's,  52 
tin,  51 
of  olecranon,  226 

internal  rigJTt-angle,  226 
long  internal,  227 
of  OS  calcis,  412 
of  patella,  344 

in  open  fracture,  350 
of  plialanges,  of  foot,  417 

of  hand,  267 
of  radius  and  ulna,  2 1 1 

after-care  of  wooden  and  tin 

splints,  216 
in  greenstick  fractures,  221 
internal  right-angle  (of  tin^ 

215,  217 
palmar  and  dorsal  (of  wood) , 
213,  217 
method     of     application, 
215 
plaster-of-Paris,  2 1 1 
after-care,  21 1 
precautions  in  using,  211 
for  Pott's  fracture: 
Dupuytren,  399,  400 
lateral  and  posterior  plaster-of- 
Paris  (Stimson's  splint),  404 
posterior  wire,  with  curved  foot- 
piece,  402 
Sponge  compresses,  342 
Sprain  of  wrist,  240 
Sternum,  101 

complications,  102 
^diagnosis,  102 
treatment,  102 
operative,  103 
Stimson,  quoted:  reduction  of  dislo- 
cations, 511 
Stimson's  splint,  404,  406,  407 
Subarachnoid  serous  exudation,  23 

indications  for  operation,  23 
Subluxation  of  head  of  radius,    175, 

201 
Surgical  neck  of  humerus,  145,  152 

after-treatment     of     operated 

cases,   152 
fracture,    with    dislocation   of 

upper  fragment,  152 
oblique    fracture    with    great 

displacement,   151 
treatment,  152 
Suturing  fracture  of  clavicle,  123,  124 
of  humerus,  shaft  of,   162 
of  jaw,  60,  72 
of  leg,  385,  389 
of  radius  and  ulna,  220 


534 


INDEX 


Suturing    in    dislocation   of    humeral 
head,  152 
results,   153 
Synovitis,  traumatic,  of  ankle,  396 
of  ell)o\v-ioinl,  226 
of  knee,  340 

Tavlok  hi])  traction  splint,  314,  483, 

485,  487 
Taylor  steel  l)ack-l)race,  103 
Teeth,  after  fracture  of  jaw,  58,  61,  63 
Temperature  in  fat  embolism,  334 
in  fracture  of  skull,   18,   19,  32,  35, 
36 
in  ])rognosis,  39 
Temporal  Ijone,  petrous  ])()rtion  of,  28 
Tenotomy  of  tendo  Achillis,  383 
Tetanus  after  a  fracture,  231 

treatment,  231 
T-fracture  into  elbow-joint,   180 
Thomas  hip-splint,  285 
application,  286 
description,  285 
Thomas  knee-splint,  481,  483 
Thomson      (Prof.      Elihu),      quoted: 
effects  of  X-rays  on  the  tissues ;  a 
personal  experiment,  456 
Three  bony  points  of  elbow  region, 

168  ^ 
Thrt)m1)osis,  394 
T-splint,   108,  283,  302 

Ulna,  coronoid  process  of,  209 
shaft  of,  209 
treatment,  217 
I'nconsciousness  from  apoplexy,  31 

in  uremia,  31 
Union  of  bones,  time  necessary  for: 
after    separation    of    lower 

femoral  epiphysis,  332 
in  Colles'  fracture,  254 
in  fracture  of  astragalus,  411 
of  bones  of  forearm,  218 
of  clavicle,  115,  122 
of  elbow,   195,   196 
of  femur,  shaft  of,  3 1 2 
of  humerus,  149,  161,  163 
in  childhood,  163 
in  the  newborn,  164 
of  ilium,  106 
of  leg,  389 
of  malar  bone,  57 
of  metatarsal  bones,  416 
of  nasal  bones,  52 
of  olecranon,  230 
of  OS  calcis,  414 
of  patella,  346 

with    operative    treat- 
ment, 356 
of  phalanges  of  hand,  269 
of  ribs,  100 


Union  of  bones,  time  necessary  for: 
of  scapula,  129 
of  sternum,  103 
in     grcenstick     fracture     of 

bones  of  forearm,  221 
in  refractures,  394 
I'nunited  fractures.     See  Nonunion. 
Urethra,    injury    to,    in    fracture    of 
pubic  bone,   106 
rupture  of,  in  fracture  of  ])elvis,  109 
extravasation,  1 10 
sympliinis,  109 
treatment,  109 

Vault  of  skull,  26 

\'eli3eau     bandage     in     fracture     of 

clavicle,  121 
Vertebrae,  73 
anatomy,  73 
dislocations,  73 

injuries  to  cervicodorsal   region, 
oppo.site  cervical  enlargement 
of  spinal  cord,  80 
injuries  to  dorsal  vertebrae,  79 
injuries     to     first     two    cervical 

vertebrae,  81 
injuries  to  last  dorsal  and  lumljar 
vertebra?,  77 
operation,  time  for,  79 
prognosis,  77 
injuries  to  midcervical  region,  80 
examination   of  an  injury  to   the 

spine,  76 
general  symptoms  common  to  frac- 
tures, 76 
gunshot  fractures,  93 

treatment,  93 
prognosis,  81 

symptoms  of  fracture  of  different 
regions  of  spine,  cord  being  in- 
volved, 77 
treatment,  81 

operative,  85,  86,  87,  90,  93,  94 
plaster-of-Paris  jacket,  90 
method  of  applying,  91 
summary,  93 
Vertical    suspension    in    fracture    of 

thigh  in  childhood,  322 
\'isceral  lesions  in  fracture  of  pelvis, 

108 
V-shaped  pad  in  fracture  of  humerus, 
146,  159 

Walton    (quoted) :    hysteroid   semi- 
consciousness, 23 
reduction  of  dislocation  of  cervical 
vertebrae,  495 
Wiring  fractured  bones  of  jaw,  60 

of  pelvis,  108 
Wounds  of  open  fractures,  cleansing, 
386 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expii'ation  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

DATE   DUE 

DATE  BORROWED 

DATE  DUE 

C2a(23S)MI00 

COLUMBIA  UNIVERSITY  LIBRARIES  (hsLstx) 

Rd  101  Scu2  1903  C.I 

The  Irnatninnt  of  irari-ir..',  wiUi  notf;r  up 


2002141507 


